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FREDERICK 

NOBMAls^  BRl       I 

VINCENT  Y.  B 

SAML.  R.  BURROUGHS^~M.d7,  ^~""'" 
Raymond,  Tex. 

J.  WELLINGTON  BYE RS,  M.D., 

Charlotte,  N.  C. 

J.  M.  DaCOSTA,  M.D., 

Philadelphia,  Pa. 
CHARLES  DENISON,  M. I)., 

Denver,  Col»). 
GEORGE  DOCK,  M.D., 

Galveston,  Texas. 
WM.  A.  EDWARDS,  M.D., 

San  Diego,  Cal. 
J.  T.  ESKRIDGE,  M.D., 

Denver,  Colo. 
SAMUEL  A.  FISK,  M.D.. 

Denver,  Colo. 
W.  H.  GEDDINGS,  M.D., 

Aiken,  S.  C. 
JOHN  B.  HAMILTON,  M.I>., 

Chicago,  111. 
T.  S.  HOPKINS,  M.D., 

Thomasville,  Ga. 
FREDERICK  I.  KNIGHT.,  M.D., 

Boston,  Mass. 
R.  L.  MacDONNELL.  M.D., 

Montreal,  Canada. 


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J I  ij .-« XV  X  m .  i,  irm  ai?}7]VI.D;, 

,„,,  ^  -         Chicago,  Ills. 

WILLIAM  OSLER,  M.D.,  °    ' 

,„,  ,■     ^  Baltimore,  Md. 

WILLIAM  PEPPER,  M.D., 
_  Philadelphia,  Pa. 

BOARDMAYREED.  M.D., 

Atiuntic  City,  N.  J. 
J.  REED,  Jr.,  M  D„ 

Colorado  Springs,  Colo, 
GEORGE  11.  ROHE,  M.D., 

Baltimore,  Md, 
KARL  VOX  RUCK,  M,D., 

Asheville,  N.  C. 
FREDK.  C.  SHATTUCK,  M.D., 

Boston,  Mass. 
S.  E,  SOLLY,  M.D., 

Colorado  Springs,  Colo. 
G.  B.  THORNTON,  M.D., 

.       Memphis,  Tcnn. 
E.L.  TRUDEAU,  M.D., 

'^   Saranac  Lake,  N.  Y. 
J,  B.  WALKER,  M.   D., 

Philadelphia.  Pa. 
J.  P.  WALL,  M.D.,  Tampa,  Florida. 
JAMES  C,  WILSON,  M.D., 

Philadelphia,  Pa. 


Yearly  Subscription  $2.00.       Single  Numbers  20  Cts. 

W.    B.    SAUNDERS,    Publisher, 

913  Walnut  Street,  Philadelphia,  Pa. 


SAUNDKRS'  QUESTION  COMPENDS,  NO.  21. 

ESSENTIALS 

OF 

NERVOUS  DISEASES  AND  INSANITY: 


THEIR 


SYMPTOMS  AND  TREATMENT. 

A  MANUAL 


FOR 


STUDENTS  AND  PRACTITIONERS. 

BY 

JOHN  C.  SHAW,  M.D., 

CLINICAL  PROFESSOR  OP  DISEASES  OF  THE  MIND  AND  NERVOUS  SYSTEM,  LONG  ISLAND 
COLLEGE  HOSPITAL  MEDICAL  SCHOOL;    CONSULTING  NEUROLOGIST  TO 
ST.  CATHERINE'S  HOSPITAL,  AND  LONG  ISLAND  COLLEGE  HOS- 
PITAL;  FORMERLY  MEDICAL  SUPERINTENDENT 
KING'S  COUNTY  INSANE  ASYLUM. 

FORTY-EIGHT  ORIGINAL  ILLUSTRATIONS. 

MOSTLY  SELECTED  FKOM  THE  AUTHOR'S  PRIVATE  PRACTICE. 


PHILADELPHIA: 

W.    B.    S  AUN  DEES, 

913  Walnut  Street. 

1892. 


COPYKIGHT,  1891. 

By  W.   B.    SAUNDERS, 


SVv  2_ 


COLLINS  PRINTING  HOUSE, 
705  JAYNE  STREET. 


INTRODUCTION  TO  THE  STUDENT. 


This  little  book  is  not  intended  to  take  the  place  of  the 
larger  and  more  complete  works  of  Ross  and  Gowers,  bat 
to  be  used  somewhat  as  a  primer — for  advanced  students. 

The  limits  of  the  book  forbade  the  introduction  of 
anatomical  detail  and  physiological  discussion.  It  is  expected 
that  the  student  will  use,  in  conjunction  with  this  volume, 
Edinger's  Lectures  on  the  Structure  of  the  Central  Nervous 
System,  translated  by  Drs.  Yettum  and  Riggs,  and  the 
small  monograph  of  Dr.  Wm.  Browning  on  the  Yessels  of 
the  Brain. 

The  headings,  under  which  some  of  the  diseases  are 
arranged,  must  be  looked  upon  as  provisional ;  such  as 
Acromegaly  under  Dystrophies,  and  Morvan's  Disease  under 
Peripheral  Neuritis.  By  a  further  advance  in  our  know- 
ledge we  may  assign  a  different  place  to  these  diseases. 
The  question  of  diagnosis  has  not  been  entered  into  fully, 
as  it  is  believed  that  a  knowledge  of  these  diseases  must 
precede  a  clear  appreciation  of  their  differential  points. 

A  few  diseases  not  frequently  met  with  have  been  omitted. 
In  the  section  on  Insanity,  the  arrangement  and  descriptions 
have  been  made  as  simple  as  possible.      Much  more  detail 

(iii) 


IV        INTRODUCTION  TO  THE  STUDENT. 

could  have  been  given,  and  other  phases  of  mental  disorder 
described,  but  it  is  believed  that  too  much  amplification 
v\rould  have  tended  to  confuse  the  student.  If,  with  clinical 
teaching,  a  few  outlines  can  be  obtained,  detail  can  be 
best  and  more  readily  added  later. 

There  is  appended  to  the  end  of  the  description  of  many 
of  the  diseases  a  Bibliography,  or  rather  a  list  of  references. 
Though  this  list  has  no  pretension  whatever  to  complete- 
ness, it  may  be  of  use  to  the  student  in  looking  up  the 
subjects,  if  he  so  desires.  Almost  all  the  references  are 
to  the  writings  of  American  neurologists.  These,  it  is 
believed,  will  be  readily  accessible  to  the  student ;  and  they 
so  fully  deal  with  the  subjects  as  to  make  reference  to  foreign 
authors  unnecessary.  The  works  of  Ley  den,  and  of  Charcot 
and  his  pupils  Kussmaul,  Nothnagel,  Westphal,  are  all  to 
be  consulted,  and  are  referred  to  in  the  description  of  the 
diseases. 

I  have  to  thank  a  number  of  medical  friends  for  many 
kindnesses — the  taking  of  photographs  of  cases  for  me,  for 
which  credit  is  given  under  the  illustrations. 

All  the  illustrations  have  been  made  by  Mrs.  J,  C.  Shaw 
from  reproductions  in  pen  and  India  ink  from  photographs 
or  other  illustrations. 

Brookltn,  N.  T.,  September  1,  1891. 


CONTENTS. 


SECTION  I. 

i:NrJURIES  AKD  DISEASES  OF  THE  PERIPHERAL 

NERVES. 

PACK 

Chapter  I. — Injuries  of  Nerves          ....  17 

Peripheral  Neuritis 20 

Multiple  Neuritis 21 

Alcoholic  Paralysis 22 

Diphtheritic  Paralysis 24 

Lead  Paralysis 25 

Acute  Infectious  Multiple  Neuritis       ....  26 

Mor van's  Disease 26 

Chapter  II.— Paralysis  of  the  Peripheral  Nerves      29 

Paralysis  of  the  Ocular  Motor 29 

Peripheral  Eacial  Paralysis  .        .        .        .        .30 

Paralysis  of  the  Musculo-Spiral  Nerve         ...      30 
from  Injury  of  the  Brachial  Plexus  during 

Birth 37 

Chapter  III. — Spasm 40 

Unilateral  Facial  Spasm 42 

Spasm  of  the  Splenius  Capitis      .        .        .        .        .43 

Writer's  Cramp 43 

Thomsen's  Disease 44 

Chapter  IV.— Neuralgia      .        .        .        .        ,        .45 

Neuralgia  of  the  Fifth  Nerve 45 

Hemicrania,  Megraine 46 

(v) 


Vi 


CONTENTS. 


PAGE 

Cervico-Occipital  Neuralgia 47 

Cervico-Brachial  Neuralgia 48 

Sciatica 48 

Herpes  Zoster .49 


SECTION  II. 
DISEASES  OF  THE  SPINAL  CORD. 

Chapter  I. — The  Acute  Inflammatory  (?)  Diseases 

OF  THE  Spinal  Cord    .        .        .        .        .51 

Acute  Spinal  Meningitis 51 

Myelitis 52 

Compression  Myelitis    .        .        .         .        .         .        .54 

Acute  Ascending  Paralysis 56 

Myelitis  of  the  Anterior  Horns  of  the  Spinal 

Cord     .         .         .         .     -  .        .        .        .58 
Myelitis  of  the  Anterior  Horns         ...      GO 


Chapter  II.— The  Degenerative  Diseases  of  the 
Spinal  Cord 
Progressive  Muscular  Atrophy 

— Peroneal  Form 
Lateral  Amyotrophic  Sclerosis 
Syringo  Myelia 


Tetanoid  Paraplegia 
Locomotor  Ataxia 
Friedreich's  Disease 
Combined  Sclerosis 
Ataxic  Paraplegia 


Chapter  III.— Muscular  Dystrophies 
Pseudo-Hypertrophic  Paralysis    . 

Acromegaly 

LocaUzatious  of  Lesions  in  the  Spinal  Cord 


62 
62 
64 
65 
67 
70 
72 
80 
84 
84 


85 
85 
89 
91 


CONTENTS.  Vll 

/ 

SECTION  III. 
DISEASES  OF  THE  BRAIN. 

PAUK 

Acute  Meningitis .90 

Meningitis  Purulent 90 

Tubercular 97 

Chronic  Hydrocephalus        .        .        .        .        .        .        .98 

Cerebral  Hemorrhage 99 

Occlusion  of  Vessels 101 

Intercranial  Tumors     .         .         .         .         .         .         .         .  103 

Abscess  of  the  Brain 100 

Disseminated  Cerebro-Spinal  Sclerosis         ....  107 

Epilepsy 109 

Paralysis  Agitans Ill 

Spastic  Hemiplegia  in  Children 114 

Cerebral  Localization 117 

Aphasia"*"^ 119 

Subcortical  Lesions 122 

SECTION  iV. 

Chorea 134 

Hereditary  Chorea 135 

Neurasthenia 130 

Headache,  Cephalalgia 138 

Exophthalmic  Goitre 140 

Angina  Pectoris  ......„„.  141 

Unilateral  Facial  Atrophy  . 142 

Hysteria 143 

Yaso-Motor  Neurosis 149 


Vlll  CONTENTS. 

SECTION  y. 

INSANITY. 

PAGE 

Chapter  I. — The  Simple  Insanities  not  Connected 

WITH  Degenerative  Neuropathic  States  154 

Melancholia 155 

Mania 160 

Senile  Dementia    .        .        .        .        ...        .        .  162 

Dementia  Terminal 163 

Chapter  II.— The  Degenerative  Insanities     .        .  164 

Paranoia        .         .         . 165 

Hysterical  Insanity 169 

Periodic  Insanities 169 

Epileptic  Insanity 172 

Alcoholic  Insanity         ........  174 

Imperative  Conceptions 177 

Hypochondria 182 

General  Paralysis  of  the  Insane 184 

Imbecility  and  Idiocy 188 


ESSENTIALS 


OF 


NERVOUS  DISEASES  AND  INSANITY. 


SECTION  I. 


mJURIES  AND  DISEASES  OF  THE  PEEIPHERAL 

NERVES. 


CHAPTER  I. 
Injuries  of  Nerves. 

The  nerves  may  be  injured  as  the  result  of  gunshot  wounds; 
tearing  injuries  by  machinery  ;  cutting  by  dull  or  sharp  instru- 
mentsl  by  falls;  or  from  the  pressure  of  cicatrices,  tumors, 
bony  exostoses,  aneurisms  in  the  subclavian,  popliteal,  or  other 
arteries  ;  from  pressure  during  parturition  ;  as  a  complication 
in  fractures  and  dislocations  •,  or  from  punctured  wounds  of  the 
nerves  themselves. 

Symptoms.  Pain  is  constant ;  it  may  be  slight  or  severe  ;  it  is 
of  a  shooting,  burning,  or  tearing  character ;  most  marked  in 
the  terminal  distribution  of  the  nerve  or  nerves  injured,  accom- 
panied with  a  feeling  of  numbness  and  heaviness  in  the  parts 
involved.  Pressure  on  the  inflamed  nerve  causes  shooting, 
tingling  pain  radiating  toward  the  periphery. 

S.  Weir  Mitchell  first  described  a  painful  burning  sensation  in 
the  parts  under  the  name  of  causalgia.  These  pains  are  often  asso- 
ciated with  glossy  skin.  In  addition  to  this  burning  sensation, 
the  parts  are  exquisitely  sensitive  ;  the  least  touch  increases 
the  pain.  Exposure  to  the  air  and  contact  is  avoided  ;  the  parts 
are  kept  carefully  covered  up  with  cloth,  oil,  water,  vaselin,  etc. 
As  the  pain  increases  the  temper  becomes  irritable,  sleep  is  dis- 
2  (17) 


18 


NERVOUS    DISEASES    AND    INSANITY. 


turbed,  the  face  exhibits  a  distressed  expression.  In  severe 
cases  trophic  disturbances  occur  ;  the  parts  are  bluish  from  im- 
paired circulation.  Bullae  may  appear ;  there  may  be  a  little 
swelling  of  the  entire  limb  below  the  injury,  but  greatest  at  the 
extremity  ;  the  joints  slightly  swollen  and  inflamed.  The  mus- 
cles in  the  distribution  of  the  injured  nerve  may  atrophy,  and 
sometimes  this  atrophy  is  exceedingly  rapid,  and  contracture 
more  or  less  marked  may  follow.  Changes  in  the  nails  are  ob- 
served ;  they  become  deformed,  brittle,  curved,  lose  their  smooth 
external  surface,  and  appear  rough  and  ridged.  Anaesthesia  is 
present  in  the  severe  cases,  and  is  in  the  distribution  of  the  in- 
jured nerve. 

Fig.  1. 


Shaded  parts  showing  the  area  of  anaesthesia  in  Drs.  McNaughton  and  Wm. 
Brownings's  case  of  injury  to  the  ulnar  nerve. 

Ulcerations  may  occur  in  the  parts  supplied  by  the  nerve ; 
the  skin  and  deeper  tissues  may  slough  in  spots  ;  the  surrounding 
parts  are  red  and  inflamed. 


INJURIES    OF    NERVES.  19 

Diagnosis.  The  history  of  an  injury  to  the  neighborhood 
of  the  nerve,  the  constant  peculiar  pains,  the  burnhig  sensation, 
its  limitation  to  the  distribution  of  a  single  nerve  or  set  of 
nerves  associated  together,  and  the  trophic  disturbances  de- 
scribed, render  the  diagnosis  comparatively  easy. 


Showing  the  ulcerated  surfaces  on  the  ulnar  side  of  the  forearm  in  Drs.  Mc- 
Naughton  and  Wm.  Browning's  case  of  injury  to  the  ulnar  nerve  by  puncture. 
Drawn  by  Mrs.  Shaw  from  a  photograph  by  Dr.  Slee.  The  wrist  is  supported  upon 
the  fingers  of  the  other  hand. 

Prognosis.  Depends  entirely  upon  the  severity  of  the  injury 
and  the  possibility  of  aid  by  medicinal  or  surgical  means.  Re- 
covery is  slow,  even  in  the  most  favorable  cases. 

Treatment.  In  division  of  the  nerve,  suture  of  the  divided 
ends  of  the  nerve  is  indicated  after  a  careful  study  of  the  case. 
For  the  indications  and  the  methods  of  applying  the  suture, 
consult  the  special  works  on  injuries  of  nerves  and  works  on 
surgery. 

In  nerve  injuries  from  pressure,  the  removal  of  the  pressure 
is  the  first  thing  to  be  done  if  that  is  possible.  In  cases  of  lace- 
rated wounds  of  the  nerves,  removal  of  any  foreign  body  from 
the  wound,  soothing  applications  to  the  inflamed  part ;  later, 
after  subsidence  of  the  inflammation,  mild  galvanism.  If  there 
results  much  inflammatory  pressure,  or  the  nerve  is  so  badly 
lacerated  that  improvement  does  not  occur,  the  advisability  of 
cutting  down  and  suturing  the  ends  must  be  considered. 

When  the  pain  is  very  severe,  morphia  will  be  necessary  to 
give  relief,  especially  at  night. 


20  NERVOUS    DISEASES    AND    INSANITY. 

Peripheral  Neuritis. 

(Acute  or  Chronic,  Inflammatory  or  Degenerative,  Local 

or  General.) 

This  is  an  inflammation  of  the  peripheral  nerves  ;  it  may  affect 
only  one  nerve,  such  as  the  median  or  ulnar  ;  or  ahnost  all  the 
nerves  may  be  affected,  when  it  is  called  poly  or  multiple 
neuritis. 

It  is  characterized  by  pain  in  the  distribution  of  the  nerve  or 
nerves  diseased  ;  the  pain  is  constant,  but  there  are  paroxysms 
of  sharp  needle-like  stabs  of  greater  or  less  severity  ;  a  sensa- 
tion of  tingling,  heaviness,  and  formication  is  not  unfrequent. 
It  has  numerous  causes,  and  as  the  etiology  somewhat  modifies 
the  clinical  picture,  we  will  consider  some  of  the  cases  from  that 
point. 

It  may  occur  without  any  assignable  cause  in  the  median  or 
ulnar  nerves,  even  in  the  musculo-spiral,  as  a  somewhat  acute 
condition.  There  is  a  feeling  of  pain,  aching,  and  oversensitive- 
ncss  in  the  peripheral  distribution  of  the  nerve,  and  to  a  greater 
or  less  extent  in  all  the  distal  side  of  the  diseased  nerve  ;  it 
will  be  found  tender  to  pressure,  and  sometimes  exquisitely  so. 
In  some  cases  the  parts  are  a  little  swollen  and  the  color  is 
darker ;  there  may  be  a  burning  sensation  in  the  peripheral 
distribution  of  the  nerve,  and  if  the  case  is  severe,  all  the  symp- 
toms described  in  cases  of  injury  to  nerves. 

In  neuritis  of  the  median  the  thumb,  index-finger,  and  the 
palm  of  the  hand  are  the  seat  of  the  burning  pain.  If  the  case 
is  severe,  glossy  skin,  bullae,  and  changes  in  the  nails,  etc.,  may 
follow.     (See  Injuries  to  Nerves.) 

In  these  cases  of  acute  and  subacute  local  neuritis  the  nerves 
in  the  upper  extremity  are  more  frequently  affected  than  any 
others. 

Diagnosis.  The  distribution  of  the  pain  to  one  nerve  ;  the 
peculiar  pain  ;  the  burning  sensation,  etc. 

Prognosis.    Most  of  these  cases  recover  under  treatment. 

Treatment.  Active  blistering  with  cantharidal  collodion 
along  the  course  of  the  nerve  ;  applying  another  blister  as  soon 


INJURIES    OF    NERVES.  21 

as  the  last  one  has  nearly  healed  ;  the  actual  cautery  may  be 
used,  but  it  is  not  nearly  as  efficacious  as  tlie  bUster.  Iodide  of 
potassa  is  sometimes  used  internally,  but  its  utility  is  doubtful. 
Mild  galvanism  appears  to  give  relief,  if  used  often  enough. 
Hot  water  applications  are  beneficial  in  the  shape  of  douches. 
There  should  be  complete  rest  of  the  part ;  for  the  relief  of  the 
pain  phenacitni  or  antifebrin  may  be  used,  but  if  the  pain  is 
very  severe,  they  are  not  sufficiently  effective.  Aconitia  some- 
times gives  rehef.  Morphia  with  atropia  is  most  effective  to 
relieve  pain  and  obtain  sleep. 


Multiple  Neuritis. 

(Poly  Neuritis  ) 

Etiology.  Two  main  causes  appear  to  operate :  1st.  The 
introduction,  or  presence  in  the  organism  of  some  organic  ma- 
terial which  is  poisonous  to  the  system,  and  shows  a  decided 
tendency  to  more  or  less  quickly  disturb  the  nutrition  and 
functions  of  the  nervous  system.  2d.  The  introduction  of  some 
inorganic  material  wliich  has  a  poisonous  influence.  Of  the 
first  group,  beginning  with  those  which  have  been  longest  and 
best  known,  we  have  alcoholic  excesses ;  the  poison  (what- 
ever that  may  be)  of  diphtheria,  typhoid,  and  typhus  fever, 
variola,  scarlatina,  measles,  enteric  fevers,  malarial  fevers, 
puerperal  disorders  and  epidemic  influences,  tuberculosis,  rheu- 
matism, diabetes,  syphilis,  etc.  Multiple  neuritis  is  known  to 
follow  all  these  conditions.  It  is  also  found  in  beri  beri  and 
leprosy,  two  conditions  only  rarely  seen  in  this  country,  but 
prevalent,  the  one  in  Japan  and  the  other  in  Oriental  countries. 
The  introduction  of  alcohol  into  the  organism  in  excess'  appears 
to  satisfactorily  explain  the  neuritis  and  changes  in  the  central 
nervous  system  ;  for  that  matter,  in  all  the  organs,  by  its  con- 
stant irritation  and  disturbance  in  nutrition.  But  the  expla- 
nation is  not  so  clear  in  the  others.  We  know  really  nothing  of 
the  material  which  gives  rise  to  typhoid,  diphtheria,  enteric  and 
malarial  fevers.  Then  we  have  a  class  of  cases,  reports  of  which 
are  just  appearing  in  medical  literature,  in  which  the  onset  of 


22  NERVOUS    DISEASES    AND    INSANITY. 

the  neuritis  is  rapid  and  fatal.  The  discovery  of  the  tubercle 
bacillus,  and  bacilli  in  other  conditions,  has  turned  the  attention 
of  pathologists  to  the  possible  relation  between  these  organisms 
and  these  infectious  diseases,  and  there  is  a  tendency  at  this 
time  to  explain  some  of  these  neurites  in  this  way. 

Then  the  discovery  that  certain  morbid  products  might  be  de- 
veloped in  the  organism  itself  from  the  products  of  food  used, 
or  from  the  products  of  waste  metamorphosis  of  the  body  ;  or, 
as  has  been  found  through  the  introduction  of  poisonous  sub- 
stances the  products  of  the  decomposition  changes  of  milli, 
cheese,  meat  and  fish  (ptomaines,  leucomaines,  etc.).  All  these 
have  given  support  to  the  theories  now  becoming  prevalent  that 
many  of  these  cases  of  poly-neuritis  are  the  result  of  some  in- 
fectious material,  either  developed  in  the  organism  or  introduced 
from  without.  It  is  thought  tliat  the  source  of  this  poisonous 
material  is  the  bacilli  of  tuberculosis  and  other  constitutional 
diseases.  The  bacteria  are  not  supposed  to  be  present  in  the 
nerves  themselves,  but  only  the  poisonous  substances  to  which 
their  growth  gives  rise.  Another  possible  source  of  infection  is 
thought  to  be  the  decomposition  products  of  the  nerve  tissue 
itself,  which  may  be  brought  about  by  a  variety  of  causes  dis- 
turbing their  nutrition. 

Of  the  second  group  we  have  the  introduction  of  mineral  sub- 
stances into  the  organism  :  lead,  arsenic  and  its  preparations, 
copper,  mercury ;  and  recently,  Jacoby  has  reported  two  cases 
from  carbonic  dioxide  poisoning. 

The  fact  that  this  form  of  neuritis  is  generalized  lends  sup- 
port to  the  theory  that  it  is  dependent  upon  some  material 
which  permeates  the  organism. 

The  etiology  somewhat  modifies  the  symptomatology  ;  so  that 
we  shall  consider  some  of  the  cases  from  that  standpoint. 


Alcoholic  Paralysis. 

At  least  two-thirds  of  the  cases  occur  in  women.  This  is  in 
keeping  with  my  personal  experience.  The  lower  extremities 
are  the  most  frequently  affected  ;  but  it  not  unfrequently  affects 


INJURIES    OF    NERVES.  23 

all  extremities,  and  it  is  said  the  pneumogastric  and  the  muscles 
of  the  face  may  be  involved.  Its  onset  is  usually  gradual.  A 
creeping,  tingling  sensation  with  soreness  is  felt  in  the  extremi- 
ties ;  some  motor  symptoms  appear  ;  the  extensors  are  the  first 
muscles  to  be  paralyzed,  iDroducing  in  the  lower  extremity 
dragging  of  the  foot,  and  in  the  upper  drop  wrist.  There  are 
sharp  shooting  pains  in  the  parts  affected.  There  is  marked 
tenderness  of  the  muscles  to  pressure,  if  the  extremities  are 
picked  up  suddenly  or  grasped  firmly.  The  patient  screams  out 
with  pain.  This  is  commonly  observed  in  women,  who  are  apt  to 
be  emotional,  and  exaggerate  their  sufferings.  There  is  a  pain- 
ful tingling  in  the  soles  of  the  feet,  which  is  much  increased  by 
standing.  They  walk  about  with  a  hobbling  gait,  and  great 
caution,  fearful  of  increasing  the  pain.  The  paretic  extremities 
are  oedematous,  bluish,  owing  to  defective  circulation.  The 
tendon  reflex  is  usually  lost.  In  not  a  small  proportion  of  these 
cases  there  is  mental  enfeeblement,  memory  is  defective,  and  they 
may  have  delusions  and  illusions.  There  may  be  some  muscular 
wasting,  but  it  is  not  great  in  the  majority  of  cases,  the  muscles 
becoming  flabby  and  soft.  Muscular  atrophy  may  occur  in  the 
cases  which  become  chronic.  Then  it  is  en  masse  as  a  rule, 
and  there  is  partial  reaction  of  degeneration.  There  may  be 
retarded  and  perverted  sensibility.  In  severe  cases  contracture 
may  occur. 

Diagnosis.  The  alcoholic  history  ;  the  association  of  the 
motor  weakness  with  the  characteristic  sensory  symptoms  in 
the  extremities ;  the  painful  tingling  in  the  feet  when  the 
patient  stands ;  the  excessive  tenderness  in  the  muscles ;  and 
the  mental  enfeeblement  make  the  diagnosis. 

Prognosis.  A  large  proportion  of  these  cases  recover  in  six 
months  to  one  year. 

Treatment.  Complete  abstinence  from  alcoholic  liquors, 
ample  nutritious  diet,  keeping  the  extremities  warm.  Hot  and 
cold  douches.  Tonics,  small  doses  of  quinia  and  strychnia.  For 
the  relief  of  the  pains  some  of  the  remedies  recommended  in 
acute  peripheral  neuritis. 


24  NERVOUS    DISEASES    AND    INSANITY. 


Diphtheritic  Paralysis. 

Diphtheritic  paralysis  occurs  usually  several  weeks  after  the 
disappearance  of  the  diphtheritic  symptoms,  and  during  the 
period  of  convalescence  or  after  it.  The  muscles  of  the  pharynx 
and  deglutition,  and  of  the  neck  are  the  most  commonly  affected  ; 
the  voice  becomes  thick  and  indistinct ;  there  is  difficulty  in 
swallowing ;  perhaps  fluids  come  out  through  the  nose  in  efforts 
to  swallow,  owing  to  paralysis  of  the  soft  palate.  The  paralysis 
in  the  muscles  of  the  neck  may  be  so  decided  that  the  child  can- 
not hold  the  head  erect.  The  paralysis  of  the  extremities  may 
be  so  slight  as  to  cause  only  an  unsteadiness  of  walk.  One  or 
more  of  the  eye  muscles  may  be  paralyzed,  and  it  is  said  one  or 
both  of  the  facial  nerves  may  be  affected.  In  severe  cases  the 
paralysis  may  be  very  decided  and  reflex  action  may  be  abolished, 
and  there  may  be  some  disorders  of  sensibility,  but  they  are  not 
marked.  There  are  none  of  the  pains  observed  in  alcoholic 
neuritis.  The  appearance  of  paralysis  has  no  relation  to  the 
severity  of  the  diphtheritic  manifestations  in  a  large  number  of 
the  eases.  I  have  seen  paralysis  follow  very  mild  cases  of 
diphtheria.  In  two  cases  the  sore  throat  and  constitutional 
symptoms  were  so  mild  that  the  children  ran  about,  and  it  was 
not  suspected  that  they  had  diphtheria. 

Diagnosis.  The  diphtheritic  history.  The  gradual  develop- 
nient  of  a  paresis  during  or  after  convalescence  ;  its  great  ten- 
dency to  affect  the  muscles  of  deglutition  and  the  neck ;  its  great 
frequency  in  children  as  compared  with  adults ;  the  absence 
of  marked  sensory  symptoms. 

Prognosis  and  Treatment.  The  uncomplicated  cases  usually 
recover  after  some  weeks.  If  the  pneumogastric  is  very  much 
involved,  or  there  is  bronchitis  or  pertussis,  the  prognosis  is 
grave.  Tonics  and  nutritious  diet  with  cod  liver  oil,  fresh  air 
if  the  weather  admits  of  being  out  of  doors,  and  at  the  same 
time  warm  clothing. 


INJURIES    OF    NERVES.  25 


Lead  Paralysis 

Occurs  in  persons  who  have  been  exposed  to  lead,  such  as 
workers  in  manufactories  of  white  lead,  and  painters  who  are 
not  careful  to  keep  their  hands  clean.  It  first  shows  itself  by  in- 
creasing pallor  and  constipation,  attacks  of  abdominal  pain, 
"  lead  colic."  There  may  be  some  pain  in  the  joints  and  limbs, 
and  a  gradually  approaching  paralysis  of  the  upper  extremities, 
usually  both.  The  extensors  of  tlie  forearms  are  most  afiected, 
so  that  when  the  arms  are  held  out  the  hand  hangs  down  and 
cannot  be  extended  from  the  wrist—"  wrist  drop."  The  conmion 
extensors  of  the  fingers  are  first  involved  ;  then  the  extensors  of 
the  index  and  little  finger  and  of  the  wrist.  The  supinator 
longus  is  not  paralyzed  unless  in  cases  of  exceptional  severity. 
There  is  swelhng  of  the  back  of  the  w^ist  from  prolonged  over- 
flexion.  The  lower  extremities  may  be  afiected  ;  but  these  cases 
are  quite  uncommon.  The  tongue  is  coated,  breath  off"ensive, 
and  there  is  usually  a  characteristic  blue  line  at  the  junction  of 
the  teeth  and  gums.  There  are  no  true  sensory  symptoms. 
and  no  pains  as  in  alcoholic  neuritis.  There  may  be  disturbances 
of  vision  due  to  optic  neuritis,  or  atrophy  of  the  optic  nerves  ; 
and  even  mental  impairment  has  been  observed,  but  it  is  not 
frequent.     A  certain  amount  of  tremor  may  exist. 

Diagnosis.  The  exposure  to  lead,  the  peculiar  abdominal 
pain,  the  drop  wrist  with  conservation  of  power  in  the  supinator 
longus.  The  blue  line  at  junction  of  gums  with  the  teeth.  The 
intense  pallor,  etc. 

Prognosis.  These  persons  usually  recover  after  a  number 
of  months,  if  the  cases  are  not  of  great  severity. 

Treatment  Sulphuric  acid,  or  some  of  the  alkaline  sulphates, 
to  wash  out  and  eliminate  the  lead.  Later,  iodide  of  potassa  in 
moderate  doses.  If  there  is  much  abdominal  pain,  it  should  be 
relieved  with  opium  or  codeia.  The  skin  should  be  kept  active 
by  moderately  warm  baths  and  rubbing  ;  the  mouth  and  teeth 
brushed  twice  a  day.  Faradism  or  galvanism  to  the  paralyzed 
muscles.     Later,  to  relieve  pallor,  mild  ferruginous  tojiics. 


26  NERVOUS    DISEASES    AND    INSANITY. 


Acute  Infectious  Multiple  Neuritis. 

In  the  last  few  years,  a  number  of  cases  of  neuritis  having  an 
acute  onset  and  rapid  termination  in  death  have  been  reported, 
with  every  indication  of  an  infectious  origin,  notably  by  Rosen- 
heim and  by  J.  J.  Putnam,  of  Boston.  The  study  of  this  phase 
of  neuritis  is  in  its  infancy,  but  it  warrants  a  brief  presenta- 
tion here.  The  symptoms  are  from  the  observations  of  Rosen- 
heim and  Putnam,  and  from  two  cases  seen  by  myself,  which 
were  quite  evidently  infectious  neuritis,  but  were  not  fatal.  A 
feeling  of  stiffness  all  over  tlie  body,  muscles  painful,  motion 
increasing  it,  gait  feeble  and  unsteady,  feebleness  in  all  the 
movements.  Temperature  and  pulse  not  materially  changed. 
A  numb  feeling  in  the  extremities,  but  no  true  disturbances  of 
sensibiUty.  The  nerve  trunks  tender  to  pressure.  Tenderness 
on  deep  pressure  of  the  muscles,  and  in  my  own  cases  tenderness 
at  the  joints,  especially  tlie  shoulder  joints,  on  pressure  or 
motion.  In  Putnam's  case  strangulation  on  attempting  to 
drink,  talkativeness,  restlessness,  and  expectoration  of  frothy 
mucus.     Death  followed  rapidly  in  the  severe  cases. 

Pathologcy.  Swelling  of  the  nerve  fibres,  breaking  up  of  the 
myeline,  absence  of  axis  cylinders  in  places.  Hemorrhages  into 
the  nerve  sheath  ;  this  condition  was  widespread  in  Rosenheim's 
case.  The  spleen  was  enlarged  and  soft,  and  in  Putnam's  case 
multiple  hemorrhages  scattered  through  both  lungs. 


Morvan^s  Disease. 

This  disease  was  first  described  by  Dr.  Morvan,  a  physician 
of  Bretagne,  France,  in  1883  ;  later  by  Prouff,  also  a  physician 
of  Bretagne  ;  by  Charcot,  and  others. 

It  is  characterized  by  neuralgic-like  pains  in  the  arms  and 
hands,  followed  by  panaris,  analgesia,  anaesthesia,  paresis,  mus- 
cular atrophy,  trophic  disorders,  and  subsequent  deformity  of 
the  parts,  more  or  less  marked. 

Its  evolution  is  exceedingly  long — ten,  fifteen,  twenty,  or 
more  years.     It  appears,  up  to  this  time,  to  have  been  observed 


INJURIES    OF    NERVES. 


27 


principally  in  Bretagne  ;  but  isolated  cases  have  been  observed 
in  other  places.  It  occurs  at  all  ages,  from  twelve  to  sixty 
years  of  age.     Men  are  oftener  affected  than  women. 

Symptoms.  Neuralgic-like  pains  in  the  fingers  and  hands 
are  one  of  the  earliest  to  appear.  These  are  followed  by  panaris, 
which  affects  one  or  more  fingers,  and  which  may  later  appear  on 
the  others  ;  it  is  usually  associated  with  analgesia,  but  excep- 
tionally it  is  absent,  and  these  ulcerations  are  painful.     Panaris 


Showing  the  deformities  of  the  hand  from  trophic  disorders  in  Morvan's  disease, 
from  an  illustration  by  Charcot  (Le  Prog.  Med.  1890). 


begins  with  redness,  heat,  and  swelling  ;  it  is  very  often  exten- 
sive, involving  not  only  the  skin,  but  the  subcutaneous  tissue, 


28  NERVOUS    DISEASES    AND    INSANITY. 

and  the  deeper  parts,  even  the  tendons,  and  there  may  be  ne- 
crosis of  the  bones  and  destruction  of  the  phalanges  ;  from  which 
there  often  result  deformities  of  the  hands.  The  lower  extremi- 
ties are  rarely  aftected.  Several  of  the  fingers,  sometimes  nearly 
all  of  them,  are  the  seat  of  these  ulcerations.  A  long  period 
of  time  may  elapse  between  the  involvement  of  each  finger — 
from  several  months  to  several  years.  There  are  cases  in  which 
the  panaris  is  painful,  but  in  the  majority  of  cases  it  is  not ; 
there  is  complete  analgesia.  Prof.  Charcot  has  pointed  out  that 
the  first  ulcerations  may  be  painful,  while  the  subsequent  ones 
are  not.  Besides  this,  there  may  be  cracks  and  indolent  ulcer- 
ations in  the  folds  of  the  skin.  The  nails  become  deformed  and 
may  fall  out,  adding  to  the  deformities.  The  hands  are  of  a 
bluish  color,  owing  to  defects  in  the  circulation.  Broca  has 
called  attention  to  scoliosis  of  the  vertebral  column,  and  this 
has  been  observed  in  half  the  cases.  Prouff  has  pointed  out  the 
presence  of  arthropathies  of  the  joints,  having  the  appearance 
of  arthritis  sicca. 

The  analgesia,  which  is  marked  and  constant,  is  confined  to 
the  upper  extremities,  and  explains  the  absence  of  pain  in  these 
ulcerated  fingers.  With  tliis  analgesia  there  is  also  anaesthesia  ; 
the  tactile  and  temperature  sense  is  much  impaired  or  abol- 
ished. 

Diagnosis.  It  may  be  mistaken  for  scleroderma,  lepra,  and 
syringo  myelia.  In  scleroderma  there  is  absence  of  true  panaris, 
anasthesia,  and  necrosis  of  the  bones.  The  deformities  in 
scleroderma  are  due  to  the  slow  absorption  of  the  tissues  of  the 
fingers,  etc. 

In  lepra  there  is  a  history  of  residence  in  a  country  where 
leprosy  exists  ;  there  are  patches  of  morphsea  over  the  body ; 
there  is  no  true  panaris  in  leprosy,  the  ulcerations  are  gan- 
grenous, and  the  lower  extremities  are  as  likely  to  be  involved 
as  the  upper.  In  syringo  myelia,  to  which  it  bears  some  resem- 
blance, the  muscular  atrophy  is  more  marked  than  in  Morvan's 
disease,  and  is  of  the  type  of  progressive  muscular  atrophy 
(Duchenne-Aran).  The  disturbances  of  sensibility  differ.'  In 
Morvan's  disease  there  are  analgesia  and  anaesthesia  ;  the  pain, 
tactile,  and  temperature  senses  are  abolished  together.      In 


PARALYSIS    OF    THE    PERIPHERAL    NERVES.        20 

syringo  myelia  tliere  are  analgesia  and  thernio-anasthesia-loss 
of  the  temperature  sense,  heat  and  cold— over  a  large  surftice, 
but  tactile  sensibility  is  not  impaired.  This  peculiar  disturbance 
of  sensation  is  characteristic  of  syringo  myelia,  and  is  found 
nowhere  else  except  rarely  in  hysteria  (Charcot).  The  trophic 
disorders  may  occur  in  syringo  myelia,  but  they  are  rare,  and 
are  not  a  part  of  the  clinical  picture,  as  they  are  in  Morvan^s 

disease. 

The  Prognosis  is  unfavorable. 

The  Pathology  is  not  clearly  made  out.  An  autopsy  by 
Gombault  points  to  its  being  a  peripheral  neuritis.  He  found 
chancres  in  the  peripheral  nerves  and  sclerosis  of  the  posterior 
columns.  Morvan  thinks  it  is  due  to  some  trophic  disorder. 
Charcot  believes  it  is  due  to  a  lesion  in  the  parts  of  the  spinal 
cord  which  preside  over  the  trophic  functions.  Joffroy  thinks 
it  is  syringo  myelia  under  a  different  manifestation. 


CHAPTER  II. 
Paralysis  of  the  Peripheral  Nerves. 

Paralysis  may  occur  in  any  of  the  nerves  supplying  the  eye 
muscles  ;  but  paralysis  of  the  3d  and  6th  nerves  is  the  most  com- 


mon. 


Paralysis  of  the  Ocular  Motor. 

This  is  most  commonly  caused  by  syphilitic  lesions  in  the 
course  of  the  nerve.  It  may  occur  after  diphtheria,  or  in  per- 
son=^  sufferino-  from  diabetes,  or  from  intracranial  tumors  ;  from 
disease  at  the  nucleus  of  origin  in  the  pons,  or  from  tumors  m 
the  substance  of  the  brain  injuring  the  nerve-tract. 
■  If  the  entire  nerve  is  paralyzed,  there  is  drooping  of  the  eye- 
lid •  and  if  it  is  extreme,  the  upper  lid  cannot  be  raised,  owing  to 
paralysis  of  the  levator  palpebrse  superioris,  causing  a  condition 
called  ptosis.  The  superior  rectus  and  the  internal  rectus  are 
also  paralyzed,  and  the  eyeball  is  turned  outwards. 


80  NERVOUS    DISEASES    AND    INSANITY. 

But  there  may  be  paralysis  in  only  a  branch  of  the  nerve. 
Tor  example,  affecting  the  internal  rectus  alone,  or  ptosis  and 
paralysis  of  the  superior  rectus  ;  and  there  may  be  dilatation  of 
the  pupil,  with  loss  of  reaction  to  light.  If  the  paralysis  is  con- 
fined to  one  eye,  it  is  due  to  a  lesion  in  the  course  of  the  nerve 
after  its  exit  from  the  brain  ;  if  the  lesion  is  in  the  nucleus  of 
origin,  the  paralysis  may  be  on  both  sides— there  will  be  double 
ptosis,  and  both  eyeballs  will  turn  outward.  If  there  is  tumor 
on  the  mid-brain,  there  will  be  the  same  condition.  (See  Dis- 
eases of  the  Brain.) 

The  Prognosis  in  these  cases  will  depend  upon  the  patho- 
logical condition  which  gives  rise  to  the  paralysis.  If  due  to 
syphilis,  recovery  may  be  expected  under  anti-syphilitic  treat- 
ment ;  if  due  to  non-syphilitic  intracranial  or  intracerebral 
tumors,  the  prognosis  is  unfavorable.  When  it  occurs  in  the 
course  of  diabetes,  it  may  pass  away.  This  may  also  occur  in 
some  of  the  cases  of  locomotor  ataxia  ;  but  in  others  it  remains 
permanent. 

Treatment.  Electricity  is  sometimes  applied  in  these  cases. 
If  there  is  evidence  of  syphilis,  large  and  increasing  doses  of 
iodide  of  potass. 

Paralysis  of  the  sixth  nerve  or  external  rectus  has  the  same 
causes  as  operate  in  paralysis  of  nerves  to  the  other  muscles  of 
the  eye  ;  it  gives  rise  to  convergence  of  the  eyeball  and  double 
vision,  or  diplopia. 

Testing  these  eye  muscles  can  be  done  easily  and  satisfac- 
torily for  a  rough  examination  by  having  the  person,  while  the 
head  is  fixed,  look  at  3-our  finger  or  a  pencil  held  up  in  front  of 
him  and  moving  it  first  to  one  side,  then  to  the  other,  upwards 
and  downwards  ;  at  the  same  time  observing  the  action  of  the 
muscles. 

Peripheral  Facial  Paralysis. 

(Bell's  Palsy.) 

This  is  a  paralysis  in  the  entire  distribution  of  the  facial 
nerve. 
Etiolc^.    Exposure  to  cold  appears  to  be  a  frequent  cause  ; 


PARALYSIS  OF  THE  PERIPHERAL  NERVES.    31 

it  may  occur  at  all  ages,  but  is  most  common  between  20  and  50 
years  of  age.  Persons  who  are  the  subjects  of  some  nervous 
disturbances,  such  as  hemicrania,  headaches,  neuralgia,  etc., 
are  more  disposed  to  this  form  of  paralysis.  It  occurs  suddenly 
in  a  large  number  of  the  cases  which  are  supposed  to  be  due  to 
cold  or  rheumatism.  It  may  occur  as  the  result  of  severe  inju- 
ries to  the  head,  causing  fracture  at  the  base  of  the  skull,  from 
sabre  cuts,  or  wounds  by  bullets  injuring  the  nerve.  It  may  be 
the  result  of  the  pressure  of  tumors  in  the  neighborhood  of  the 
parotid  gland,  from  si^ppurative  otitis,  with  extensive  disease 
of  the  bone.  It  may  arise  from  the  pressure  of  syphilitic  perios- 
titis in  the  bony  canal  or  syphilitic  meningitis  and  gummata, 
or  in  the  course  of  the  development  of  neoplasms  (sarcoma  and 
other  tumors)  at  the  base  of  the  brain  ;  but  the  symptoms  then 
are  not  single  paralysis  of  the  facial  nerve  ;  other  cranial  nerves 
are  involved,  and  other  symptoms  indicative  of  tumor  are 
present. 

Symptoms.  There  may  be  some  premonitory  symptoms,  such 
as  a  general  feeling  of  discomfort,  chilliness,  some  headache, 
slight  pain  about  the  ear  or  the  side  of  the  head,  slight  noise  in 
the  ear,  or  tingling  sensation  in  the  side  of  the  tongue.  Often 
the  person  awakes  in  the  morning  to  find  the  face  on  one  side 
paralyzed,  or  his  attention  is  first  called  to  it  by  some  person. 
The  entire  side  of  the  face  is  paralyzed,  the  naso-labial  fold  is 
obliterated,  the  lower  eyelid  droops  down  so  that  the  tears  can 
run  over  on  the  cheek  ;  there  is  a  peculiar  stare  about  the  eye, 
owing  to  the  paralysis  of  the  orbicularis  palpebrarum  ;  that  side 
of  the  forehead  looks  smoother  than  the  other  ;  all  wrinklino-  of 
the  skin  is  obliterated.  If  the  person  is  asked  to  close  the  eyes 
tightly,  he  cannot  close  the  affected  eye  ;  the  ball  is  only  par- 
tially covered.  If  the  tongue  is  protruded,  the  upper  lip  on  that 
side  is  observed  to  hang  lower  than  the  opposite  side  ;  it  touches 
the  tongue.  In  making  an  efibrt  to  whistle,  the  lips  on  the 
affected  side  do  not  contract  as  they  do  on  the  opposite  side. 
The  healthy  side  appears  drawn  up,  and  leads  the  student 
and  friends  to  think  that  it  is  the  affected  side  ;  it  is  due  to  the 
great  contrast  between  the  healthy  muscles  in  tone  and  the 
fl.accid  paralyzed  muscles  on  the  other  side.    If  the  nerve  is  dis- 


82  NERVOUS    DISEASES    AND    INSANITY. 

eased  external  to  the  Fallopian  canal,  all  the  muscles  of  the 
face  on  that  side  are  paralyzed  ;  if  in  the  Fallopian  canal 
and  below  the  point  at  which  the  chorda  tympani  is  given  off, 
the  muscles  of  the  external  ear  in  addition  are  paralj'zed.  If 
the  disease  is  between  the  point  at  which  the  chorda  tympani 
is  given  off,  and  the  point  of  origin  of  the  small  branches  of  the 
stapedius,  we  have  in  addition  abolition  of  taste  in  the  anterior 
two-thirds  of  the  tongue  on  that  side,  diminution  of  salivary 
secretion,  and  pain  of  a  tingling  and  burning  character  in  these 
parts  may  be  present.  If  the  geniculate  ganglion  itself  is  dis- 
eased, all  the  previous  signs  are  present,  and  in  addition  par- 
alysis of  the  soft  palate  and  displacement  of  the  uvula.  At  the 
very  beginning  of  the  paralysis  there  is  an  increased  irritability 
to  the  faradic  reaction,  but  it  is,  as  a  rule,  soon  lost,  and  we 
have  for  galvanism  the  reaction  of  degeneration.  During  the 
course  of  the  disease,  there  is  a  good  deal  of  annoyance  and 
distress,  due  to  inability  to  close  the  eyelids ;  dust  is  blown 
in,  and  in  high  dry  winds  the  tears  are  rapidly  evaporated  ; 
the  inability  to  cover  the  ball  from  time  to  time  allows  it  to 
become  diy,  irritated,  and  painful.  This  is  much  less  trouble- 
some in  moist,  damp,  foggy  weather.  (The  lip  is  in  the  way 
when  they  attempt  to  bite  or  chew,  and  often  gets  bitten.) 
Later,  if  the  paralysis  is  not  completely  recovered  from,  there 
is  a  certain  amount  of  contracture  in  the  paralyzed  muscles  ; 
there  is  a  feeling  of  stiffness  in  them. 

Diagnosis.  In  peripheral  facial  paralysis  all  the  muscles 
supplied  by  the  facial  are  paralyzed.  If  the  person  is  directed 
to  close  the  eyes,  he  cannot  close  the  eyelids  on  the  paralyzed 
side.  In  the  facial  paralysis  from  cerebral  disease  only  the 
lower  facial  muscles  are  affected,  and  he  can  close  both  eyes 
equally  well.  There  is  an  exception  to  this,  and  it  is  when 
there  is  a  lesion  in  the  pons  or  medulla  ;  but  these  cases  are  ex- 
ceedingly rare.     (Refer  to  chapters  on  Diseases  of  the  Brain.) 

In  cases  due  to  fracture  at  the  base  of  the  skull  there  will  be 
a  history  of  severe  injury,  with  perhaps  bleeding  from  the  ear, 
etc.  From  disease  of  the  bones  of  the  ear  there  will  be  a 
history  of  old  suppurative  inflammation  of  the  middle  ear,  with 
an  offensive  bloody  discharge. 


PARALYSIS  OF  THE  PERIPHERAL  NERVES. 


;3 


In  the  paralysis  due  to  syphilitic  disease  there  will  be  head- 
ache and  a  slowly  advancing  paralysis,  not  sudden,  as  is  the  case 
with  the  common  variety,  also  a  history  of  syphilis,  and  there 
is  very  likely  to  be  paralysis  of  some  of  the  other  cranial  nerves  ; 
those  supplying  the  eye-muscles  are  much  oftener  affected. 

Prognosis.  In  the  cases  due  to  fracture  at  the  base  of  the 
skull  ;  to  caries  of  the  temporal  bone,  and  to  intracranial 
tumors,  the  prognosis  is  unfavorable.  In  those  cases  clearly  due 
to  syphilis,  under  appropriate  treatment,  recovery  is  the  rule. 
In  the  cases  due  to  cold,  recovery  is  complete  in  some  of  the 
cases  after  a  few  weeks  ;  in  the  more  severe  cases,  recovery 
occurs  only  after  six  or  eight  months,  and  there  is  very  apt  to 
remain  some  slight  impairment  of  the  muscles  and  nerve  on 
that  side. 

Fig.  4. 


Cervical  plexus  of  nerves.    After  Flower  (Keen  edition). 


Treatment.  Galvanism  is  to  be  applied  every  day  to  these 
paralyzed  muscles.  If  there  is  much  pain  about  the  ear,  a  small 
blister  will  afford  instant  relief.  If  the  person  is  in  poor 
physical  condition,  tonics  should  be  given.  Iodide  of  potassa  is 
sometimes  given  in  these  cases  ;  but  I  doubt  its  being  of  any 
value,  except  in  those  cases  which  are  clearly  syphilitic  ;  then  it 
3 


34  NERVOUS    DISEASES    AND    INSANITY. 

Fig.  5. 


1 1^ ,'.;. 


Brachial  plexus. 


PARALYSIS  OF  THE  PERIPHERAL  NERVES 


35 


should  be  given  in  steadily  increasing  amounts  until  very  large 
doses  are  taken  ;  inunctions  of  mercurial  ointment  should  be 
used  as  well.  In  the  cases  due  to  intracranial  tumor,  unless 
gummata,  there  is  no  treatment  which  does  any  good.  In  the 
cases  due  to  middle  ear  disease  the  condition  of  the  ear  requires 
treatment. 

Paralysis  of  the  median  nerve  causes  inabihty  to  pronate  and 
grasp  objects  with  the  hand,  except  with  the  two  fingers  which 
are  supplied  by  the  ulnar  nerve.  There  may  be  a  good  deal  of 
anaesthesia  in  the  distribution  of  the  nerve.  Its  most  common 
cause  is  injury. 

Paralysis  of  the  ulnar  abolishes  the  power  to  flex  the  last  two 
fingers,  of  separating  or  of  compressing  them  against  the  middle 
finger,  of  flexing  the  first  and  extending  the  second  and  third 

Fig.  6. 


Paralysis  of  the  ulnar  nerve.     Clinic,  Long  Island  College  Hospital.    Dr.  Win. 
Browning's  case.    From  a  photograph  by  Dr.  C.  N.  Hoagland. 

phalanges  of  all  the  fingers,  and  of  adducting  the  thumb  and 
placing  it  against  the  metacarpal  bone  of  index  finger.  If  the 
interossei  and  lumbricales  are  alone  paralyzed,  the  combined 


36  NERVOUS    DISEASES    AND    INSANITY. 

traction  of  the  extensors  and  flexors  of  the  fingers  produces 
hyperextension  of  the  first  and  flexion  of  the  last  two  phalanges, 
and  the  liand  assumes  a  claw-like  appearance  (see  cut). 


Paralysis  of  the  Musculo-Spiral  Nerve 

Is  most  frequently  due  to  injuries  as  it  winds  around  the 
humerus.  One  of  the  most  common  causes  is  compression  of  the 
nerve  from  lying  on  the  arm  in  such  a  way  as  to  press  against  some 
hard  substance.  This  frequently  occurs  in  drunkards  who  fall  in 
almost  any  place,  on  a  hard  floor,  or  on  the  stones  in  the  street. 
When  thej^  awake  the  next  morning  the  arm  is  found  paralyzed, 
they  cannot  extend  the  wrist  and  the  fingers  ;  the  thumb  is 
flexed  and  abducted.  They  are  unable  to  supinate  the  fore- 
arm ;  and  it  will  be  found  that  the  supinator  longus  is  paralyzed. 
This  can  be  shown  by  having  the  patient  flex  the  forearm  upon 
the  arm,  and  make  resistance  to  passive  extension.  If,  while  you 
make  the  effort  to  extend  it,  a  finger  is  placed  on  the  supinator 
longus  just  below  the  elbow,  it  will  be  found  to  be  quite  flaccid- 
paralyzed.  In  plumbism  the  paralysis  in  the  upper  extremities 
is  in  the  distribution  of  the  musculo-spiral,  and  it  presents, 
therefore,  in  that  respect  the  same  symptoms  as  in  the  condition 
under  consideration.  This  difference  in  the  condition  of  the 
supinator  longus  can  be  used  as  one  of  the  points  of  differential 
diagnosis.  In  lead  paralysis  it  is  not  involv^ed  ;  in  paralysis  from 
I)ressure  it  is.  It  is  paralyzed  by  improperly  adjusted  crutches, 
and  b}-^  injuries  which  partially  or  entirely  sever  the  nerve.  In 
these  cases  there  is  anaesthesia  on  the  back  of  the  hand  and 
forearm. 

Paralysis  of  the  circumflex  nerve  is  shown  by  paralysis  of  the 
deltoid.  The  arm  cannot  be  raised  upward  or  outward  ;  the 
muscle  is  observed  to  remain  relaxed  in  these  efforts  ;  and  it 
frequently  undergoes  atrophy.  Its  most  common  cause  is  injury 
by  falls  or  blows,  and  the  muscle  is  more  or  less  injured  at  the 
same  time.    There  may  be  some  slight  aching  about  the  shoulder. 


PARALYSIS  OF  THE  PERIPHERAL  NERVES.    87 

Paralysis  from  Injury  of  the  Brachial  Plexus 
During  Birth. 

(Obstetrical  Paralysis.     Erb's  Paralysis.) 

This  is  a  form  of  paralysis  in  one  arm,  occurring  in  very 
young  children,  from  injury  to  the  fifth  and  sixth  cervical  nerves 
by  forcible  traction  on  the  head  and  neck  during  delivery  by  the 
obstetrician.  The  muscles  paralyzed  are  the  deltoid,  biceps, 
brachialis  anticus,  infraspinatus  and  supinator  longus,  and  occa- 
sionally the  extensors  of  the  hand.  The  arm  hangs  by  the  side  ; 
it  cannot  be  raised  from  the  shoulder,  or  flexed  at  the  elbow, 
but  the  forearm  and  hand  can  be  moved.  In  some  cases  the 
hand  is  flexed  and  rotated  inwards ;  there  is  anaesthesia  on 
outer  side  of  shoulder  and  arm. 

Erb  considers  the  prognosis  in  these  cases  unftivorable  ;  Starr 
has  seen  some  of  them  recover.  In  the  cases  which  I  have  seen, 
improvement  took  place,  but  was  very  slow ;  and  I  am  unable 
to  say  if  recovery  occurred  in  any  of  them.  Treatment.  Gal- 
vanism to  the  afl'ected  nerve  and  muscles  and  friction.  Starr 
recommends  keeping  the  elbow  flexed,  and  not  allowing  the 
hand  to  hang  down  to  prevent  overstretching  of  the  shoulder 
ligaments. 

Paralysis  of  the  laryngeal  branches  of  the  vagus  may  occur 
from  injuries,  or  compression  of  these  nerves  by  tumors  in  the 
neck  or  mediastinum,  by  enlarged  lymphatic  glands,  aneurisms 
in  the  arch  of  the  aorta,  carotid,  and  subclavian  arteries.  It  is 
met  with  sometimes  as  a  symptom  in  hysteria,  in  disseminated 
sclerosis,  in  bulbar  paralysis,  and  in  locomotor  ataxia,  and  as  the 
result  of  lesions  in  the  corpus  striatum  and  its  vicinity.  (See 
Diseases  of  the  Brain.) 

Symptoms.  It  may  give  rise  to  difficulty  in  breathing,  diffi- 
culties in  speech  ;  depending  upon  the  muscles  paralyzed  ;  or 
there  may  be  paroxysms  of  spasmodic  coughing,  as  when  the 
nerve  is  irritated  by  the  pressure  of  tumors  or  aneurisms,  or  as 
in  locomotor  ataxia  (see  that  disease). 

Paralysis  of  the  lumbar  and  sacral  plexus  and  its  branches 


38  NERVOUS    DISEASES    AND    INSANITY 


Fig.  7. 


Lumbar  plexus. 


PARALYSIS    OF    THE    PERIPHERAL    NERVES.        39 


40  NERVOUS    DISEASES    AND    INSANITY. 

may  arise  from  injuries,  diseases  of  the  vertebrae,  tumors,  ab- 
scesses, fracture  of  the  thigh,  etc. 

Paralysis  of  the  anterior  crural  nerve  causes  inability  to  flex 
the  thigh  on  tlie  hip,  and  extension  of  the  leg.  If  sensory  dis- 
orders are  present,  it  is  over  the  lower  two- thirds  of  the  thigh, 
the  laiee  and  inner  side  of  the  leg  and  foot. 

If  the  obturator  nerve  is  paralyzed,  adduction  of  the  thigh 
and  crossing  this  leg  over  the  other  are  impossible  ;  outward  rota- 
tion of  the  thigh  is  difficult.  Anaesthesia  is  on  the  inner  side  of 
the  thigh  as  far  as  knee. 

In  paralysis  of  the  musculo-cutaneous  and  anterior  tibial  the 
foot  cannot  be  flexed,  but  hangs  down  ;  in  walking  the  toes 
drag,  and  the  person  is  in  danger  of  tripping  ;  to  avoid  this  the 
leg  is  lifted  very  high  by  flexion  of  the  thigh  on  the  hip  and  at 
knee.  This  is  a  condition  frequently  observed  in  infantile  and 
other  spinal  paralyses.  Sensory  disorders,  if  present,  are  in  the 
anterior  and  external  part  of  the  leg,  dorsum  of  the  foot  and 
toes. 

In  paralysis  of  the  trunk  of  the  sciatic,  all  the  muscles  of  the 
leg  and  foot  are  paralyzed.  There  may  be  all  the  trophic  dis- 
orders described  under  injuries  of  nerves,  and  muscular  atrophy 
may  follow. 


CHAPTER  III. 
Spasm. 

Spasm  may  occur  in  the  distribution  of  any  of  the  peripheral 
nerves  or  its  branches.  Ordinary  cramp  or  transient  spasm  is 
very  common.  A  study  of  the  cases  and  reference  to  the  dia- 
gram of  the  nerves  and  their  distribution  to  the  muscles  will  be 
a  guide.  The  commonly  met  with  spasmodic  conditions  are  as 
follows : — 

Spasm  of  the  muscles  supplied  by  the  spinal  accessory  nerve. 

It  may  be  tonic  or  clonic.     It  is  usually  observed  in  persons  of 


SPASM. 


41 


a  strong  neuropathic   tendency,  those  whose  families  arc  the 
subjects  of  hysteria,  iusauity,  and  other  nervous  disorders. 

The  immediate  cause  and  the  exact  location  of  the  irritation 
which  give  rise  to  these  spasms  are  unknown.  If  the  spasm  af- 
fects the  sterno-cleido-mastoid,  the  head  is  drawn  backward  and 
to  one  side,  the  chin  turned  upwards  and  to  one  side,  and 
raised.  If  the  trapezius  is  aflected,  the  head  is  drawn  back- 
wards and  towards  the  affected  side  without  rotation  of  the  chin, 
the  shoulder  is  raised.  It  is  rarely  confined  to  the  muscles  sup- 
plied by  the  spinal  accessory  ;  the  spleuius  is  often  affected  ; 
lateral  curvature  of  the  spine  may  be  observed  in  some  of  the 
chronic  cases.  It  usually  begins  with  uneasiness  in  the  neck. 
Soon  the  head  begins  to  be  turned  slowly  to  one  side  ;  as  soon  as 
the  spasm  relaxes,  the  head  returns  to  the  normal  attitude.  The 
spasm  is  repeated  again  in  a  short  time  with  the  same  relaxa- 
tion.    The  frequency  with  which  this  recurs  varies.     As  the 

Fig.  9. 


condition  becomes  more  chronic,  the  head  may  remain  perma- 
nently in  that  position.     At  first,  by  an  effort  of  the  will  or  the 
hand,  the  head  can  be  brought  to  the  normal  position,  but  it  at 
once,  upon  being  released,  returns  to  the  abnormal  attitude. 
Prognosis  is  not  favorable  in  these  cases.     Some  of  them  re- 


42  NERVOUS    DISEASES    AND    INSANITY. 

cover,  but  very  few  ;  and  there  is  a  great  tendency  for  them  to 
relapse. 

Treatment  is  most  unsatisfactory  :  of  medicines,  hypodermic 
injections  of  atropia  in  gradually  increasing  doses,  beginning 
with  the  j^o  or  g^o  of  a  grain  twice  a  day,  gives  the  best  re- 
sults, but  it  is  not  always  successful.  The  nerve  and  the 
muscles  have  been  divided  but  no  permanent  good  results  have 
been  obtained.  Recently,  W.  W.  Keen,  of  Philadelphia,  has 
devised  and  carried  out  an  operation  for  the  relief  of  this  con- 
dition (Annals  of  Surgery,  January,  1891).  It  consists  in 
division  and  exsection  of  the  posterior  divisions  of  the  first  three 
cervical  nerves  by  which  the  chief  posterior  rotators  of  the  head, 
the  splenius  capitis,  rectus  capitis,  posticus  major,  and  the 
obliquus  inferior  are  supplied. 

Unilateral  Facial  Spasm. 

It  is  supposed  to  occur  in  neuropathic  subjects.  Reflex  irri- 
tations from  the  eyes,  teeth,  nose,  or  any  inflammatory  focus  in 
the  distribution  of  the  corresponding  branches  of  the  fifth  nerve 
are  also  asserted  by  some  to  be  causes.  I  believe  very  little,  if 
any  thing,  is  known  of  the  etiology  of  this  condition.  In  all 
the  cases  which  I  have  seen  a  careful  examination  of  every 
possible  source  of  irritation  has  been  made  without  any  satis- 
factory result.  Almost  all  of  them  have  been  in  women  over 
40  years  of  age  ;  one  was  a  woman  of  25  years. 

Symptoms.  Clonic  spasm  in  the  distribution  of  the  facial 
nerve  ;  the  muscles  about  the  eye  are  more  constantly  the  seat 
of  the  spasm,  even  when  all  the  muscles  take  part  paroxysmally 
in  this  spasm.  Some  cases  are  so  severe  that  for  the  time  being 
the  eye  is  entirely  closed,  and  the  mouth  drawn  far  to  one  side, 
the  alse  of  the  nose  also  drawn  up.  It  may  last  for  years,  but 
there  are  times  when  the  paroxysms  are  much  more  frequent 
and  severe  than  at  others. 

Treatment.  I  know  of  no  treatment  which  gives  the  slightest 
relief  in  these  cases,  and  this,  after  the  most  careful  trial  of  all 
kinds  of  medicaments  and  electricity. 


SPASM. 


43 


Spasm  of  the  Splenius  Capitis 

Sometimes  occurs  ;  it  causes  the  head  to  be  drawn  backwards 
and  towards  the  affected  side,  tlie  chin  somewliat  depressed  and 

Fig.  10. 


directed  towards  the  affected  side, 
tonic. 


The  spasm  is  principally 


Writer's  Cramp. 

(And  other  Professional  Hyperkinesia.) 

Writer's  cramp  is  one  of  a  group  of  cramps  met  with  in  per- 
sons of  a  highly  nervous  temperament  and  of  neuropathic  inheri- 
tance, and  developed  by  special  occupations.  It  is  a  spasm  in 
the  muscles  associated  together  in  the  performance  of  some 
work  requiring  delicacy  and  more  or  less  long  continued  or 
severe  action  of  those  muscles,  such  as  is  required  in  writing, 
pianoforte  playing,  sewing,  telegraphing,  etc.  In  some  of  the 
cases  as  soon  as  the  person  attempts  to  use  the  hand  the  muscles 


4-i  NERVOUS    DISEASES. AND    INSANITY. 

are  seized  with  tonic  or  clonic  spasms,  so  that  the  intended  act 
cannot  be  performed.  In  otliers  tlie  attempt  to  use  the  hand 
brings  on  a  trenmlous  condition,  and  if  writing  be  the  act  at- 
tempted, it  is  uneven,  coarse,  and  imperfect.  In  others,  and 
perhaps  tlie  most  common  manifestation  of  the  difficult}?-,  the 
person  experiences  great  fatigue,  weakness,  and  aching  in  the 
hand  and  forearm,  at  times  even  in  the  shoulder ;  if  the  work 
or  the  pen  be  laid  aside,  the  feeling  may  disappear.  In  such  per- 
sons, if  they  attempt  to  write  with  the  left  hand,  sooner  or  later 
it  is  affected  in  tlie  same  way  as  the  right. 

Thomsen's  Disease. 

This  condition  deserves  a  passing  notice  here.  It  is  not  fre- 
quently seen.  It  was  first  described  by  Thomsen,  who  was 
himself  a  sufferer.  It  is  often  inherited,  and  may  appear  iu 
several  members  of  a  fan^iily.  It  is  characterized  by  stiffness 
and  rigidity  of  the  muscles  as  soon  as  voluntary  motion  is 
attempted,  and  it  may  be  so  great  as  to  prevent  all  motion.  If 
they  attempt  to  take  hold  of  any  article  the  muscles  contract 
very  slowly,  but  when  the  object  is  once  grasped  it  is  not 
readily  released,  as  they  in  turn  relax  very  slowly.  Rest  ap- 
pears also  to  make  the  muscles  stiff,  and  they  experience  great 
difficulty  in  beginning  a  voluntary  act.  In  some  cases  the 
muscles  of  the  back  are  affected,  and  there  is  a  spasmodic 
lordosis  ;  the  movements  of  the  tongue  may  be  interfered  with, 
and  a  patient  of  Ballet  and  Marie  found  that  if  he  turned  his 
eyes  upward  they  became  fixed,  and  he  had  difficulty  in  changing 
their  position. 


NEURALGIA.  45 


CHAPTER  lY. 

Neuralgia. 

Neuralgia  of  the  Fifth  Nerve. 

(Trifacial  Neuralgia.) 

Heredity  is  said  to  play  a  part  in  its  predisposing  causes. 
It  has  been  observed  to  affect  several  generations  of  a  family. 
It  is  frequent  in  those  disposed  to  neuralgias  and  other  nervous 
diseases.  It  is  most  common  in  middle  and  advanced  life  ;  it 
is  more  frequent  in  w^omen  than  in  men.  Anaemia  and  general 
disorders  of  nutrition,  from  whatever  cause,  predispose  to  it. 
Malarial  infection  is  a  common  cause  ;  cold  drafts  from  open 
windows,  wounds,  diseases  of  the  parts  in  the  neighljorhood  of 
the  nerve  and  its  branches,  disease  of  the  cranial  bones,  perios- 
titis, exostosis,  injuring  the  nerve  as  it  passes  through  its  bony 
canals  ;  intracranial  tumors  ;  tumors  developing  on  the  nerve 
itself.     Disease  of  the  teeth  and  nose  is  an  occasional  cause. 

Sjn^iptoniS.  Pain  in  the  distribution  of  the  nerve  of  more  or 
less  severity  ;  it  is  sharp,  shooting  in  character,  coming  in  par- 
oxysms. The  entire  nerve  may  be  involved  ;  but  the  ophthal- 
mic or  supraorbital  branches  are  the  most  frequently  affected. 
Supraorbital  neuralgia.  When  the  superior  or  inferior  maxillary 
branches  are  implicated  the  pain  is  felt  in  the  teeth.  If  the  at- 
tack is  severe,  there  is  constant  pain,  with  paroxysms  of  intense 
lightning-like  pain.  If  the  attack  has  been  of  some  duration, 
tender  spots  will  be  found  at  various  places,  usually  where  the 
nerve  becomes  more  superficial.  The  skin  is  often  hyperesthetic, 
and  in  some  chronic  cases  there  may  be  some  au?esthesia.  After 
the  attack  is  well  established,  the  face  is  red  and  the  local  tem- 
perature may  be  elevated.  The  arteries  on  that  side  pulsate 
violently,  and  there  may  be  an  abundant  flow  of  tears. 

Prognosis.  The  majority  of  these  cases  recover  ;  but  there  is 
a  proportion  which  are  very  obstinate— those  in  which  serious 


46  NERVOUS    DISEASES    AND    INSANITY. 

nutritive  changes  play  a  part  in  the  causation.  There  is  also  a 
proportion  in  which  medicinal  treatment  does  very  little  good. 
Treatment.  In  those  which  have  a  suspicion  of  malaria  as 
the  exciting  cause  quinine  5  or  10  grains  at  night,  and  the  ^Iq 
of  a  grain  of  aconitia  taken  2  or  3  times  a  day,  preceded  by  a  mer- 
curial cathartic,  will  almost  certainly  cure  them.  This  treat- 
ment will  often  cure  cases  that  are  apparently  not  malarial. 
Sometimes  15  or  20  grain  doses  of  phenacetin  will  give  the  de- 
sired result.  If  there  is  antemia,  iron  in  one  of  its  preparations 
should  he  given,  or  arsenious  acid  and  a  generous  diet,  with 
butter,  fats,  cream,  or  cod-liver  oil,  and  fresh  air  with  moderate 
exercise.  In  some  troublesome  cases,  phosphorus  may  give 
some  benefit.  If  it  is  suspected  that  the  neuralgia  is  caused  by 
carious  teeth,  they  should  be  examined  by  some  good  dentist. 
Those  cases  dependent  upon  disease  of  the  bones  must  be  treated 
by  the  surgeon.  In  those  cases  incurable  by  medicine,  opera- 
tions on  the  nerve  have  often  given  relief  for  long  periods  of 
time.  There  is  a  tendency  to  recurrence  of  the  pain  even  in 
these  cases. 

Hemicrania,  Megraine. 

(Sick  Headache.) 

This  is  essentially  a  neuralgia  of  the  fifth  nerve,  with  some 
special  manifestations.  Its  most  common  cause  is  heredit}'',  and 
a  neuropathic  constitution.  Families  in  which  there  are  hyste- 
ria, neurasthenia,  epilepsj'',  asthma,  dipsomania,  and  insanity  are 
most  likely  to  have  it  ;  and  it  is  often  transmitted  directly.  In 
these  predisposed  persons  it  may  be  brought  about  by  all  the 
causes  which  give  rise  to  neuralgia  in  general.  Excessive 
fatigue,  anxiety,  and  worry  often  bring  on  an  attack.  It  often 
begins  in  childhood  or  youth,  and  ceases  at  40  or  50 ;  but  it 
msij  begin  in  a.dvanced  life. 

It  is  most  common  in  women. 

It  is  characterized  by  headache  which  comes  on  in  paroxysms 
and  lasts  for  many  hours.  It  is  frequently  located  in  one  temple, 
and  it  is  said  in  the  left  side  most  frequently.  But  in  a  large 
proportion  of  the  cases  it  is  more  or  less  diftuse,  extending 


NEURALGIA.  47 

backwards  to  the  occiput  and  neck  or  the  top  of  the  head,  or  it 
may  be  on  both  sides.  The  pain  is  usually  dull,  severe,  and 
deep-seated,  but  there  may  be  from  time  to  time  stabbing  pain 
as  in  common  neuralgia  of  the  fifth  nerve.  At  the  outset  or 
during  the  attack  there  may  be  tingling  and  numbness  in  the 
side  of  the  face  or  arm  ;  indistinctness  of  vision,  hemianopsia, 
difficulty  in  speaking,  aphasia,  flashy  or  colored  light  before 
eyes.  The  arteries  of  the  side  of  greatest  pain  may  pulsate 
with  great  force  ;  the  face  may  be  red  or  pale  :  light,  noise,  and 
motion  are  distressing  ;  vomiting  may  or  may  not  occur ;  the 
pupil  may  be  slightly  dilated  on  the  side  of  greatest  pain.  As 
the  attack  subsides  there  is  an  abundant  secretion  of  pale  urine. 
The  frequency  with  which  these  attacks  occur  varies  very  much. 
It  is  susceptible  of  relief,  but  it  is  not  curable. 

Treatment.  If  the  nutrition  is  impaired,  as  it  frequently  is  in 
the  neuralgias,  tonics,  nutritious  diet,  cod-liver  oil,  cream,  etc., 
are  indicated,  friction  to  the  body  by  a  coarse  towel  or  rubbing 
with  cold  water.  Extract  cannabis  indica  in  §^  to  ^  grain  doses 
combined  with  quinine  and  continued  for  some  time  does  most 
good  among  the  medicinal  remedies  used.  For  the  relief  of  the 
paroxysms  a  number  of  things  may  be  tried  :  glonoin,  guarana, 
citrate  of  caffein,  aconitia,  and  antipyrine  ;  the  three  last  are  the 
most  efficacious  and  certain.  Some  persons  are  relieved  by  one 
remedy  which  gives  no  relief  to  another.  A  remedy  which  has 
been  efficacious  in  one  paroxysm  may  fail  in  the  next.  Morphia 
gives  relief  in  some  persons,  but  it  is  a  dangerous  remedy,  as 
these  persons  are  very  apt  to  contract  the  habit  of  taking 
morphia  in  spite  of  their  thinking  they  never  will.  I  have 
known  morphia  taken  by  the  mouth  to  give  very  little  relief. 
Antipyrine  requires  to  be  given  in  15  grain  doses  to  adults. 
Eelief  is  in  some  cases  obtained  by  5  or  10  grains  of  menthol  in 
hot  water. 

Cervico-Occipital  Neuralgia 

Is  characterized  by  pain  in  the  distribution  of  the  occipital 
nerve,  but  it  may  and  often  does  radiate  into  the  distribution 
of  the  cervical  nerves. 


48  NERVOUS    DISEASES    AND    INSANITY 


Cervico-Brachial  Neuralgia, 

The  pain  here  is  in  the  distribution  of  the  cervical  and  brachial 
nerves,  and  is  of  the  same  character  as  in  the  neuralgias  of  the 
fifth  nerve,  but  more  constant  and  dull  and  less  exactly  localized. 
We  may  also  have  neuralgia  in  the  distribution  of  the  dorsal 
nerves ;  intercostal  neuralgia ;  and  in  tlie  lumbo-abdorainal 
nerves. 

Sciatica. 

Of  all  the  neuralgias,  that  of  the  fifth  nerve  and  the  sciatic 
are  by  far  the  most  common.  Sciatica  occurs  most  frequently 
between  the  ages  of  40  and  50,  but  it  may  occur  in  younger 
persons,  especially  those  living  in  malarious  regions.  After  30 
years  of  age  it  is  most  common  in  males.  It  may  be  caused  by 
injuries,  blows,  and  falls,  from  pressure  during  parturition  ;  from 
sitting  on  hard  seats  ;  vertebral  caries.  Grout,  rheumatism,  and 
syphilis  are  among  its  most  common  causes. 

The  pain  is  in  the  distribution  of  the  sensory  branches  of  the 
sciatic.  Tliere  is  at  first  a  feeling  of  heaviness  and  tingling  in  the 
leg,  which  tires  easily  and  aches.  "When  the  pains  begin  they 
are  lightning-like  or  tearhig.  Motion  of  the  limb  increases  it, 
and  sometimes  the  sensitiveness  is  so  great  that  the  person  cannot 
move  without  severe  pain,  and  has  to  keep  in  one  position.  The 
pain  is  usually  felt  at  the  back  of  the  thigh  down  to  the  popliteal 
space.  The  outer  surface  and  dorsum  of  the  foot  may  also  be 
painful.  There  may  be  more  or  less  drawing  up  of  the  leg,  and 
cramp  in  the  muscles,  especially  at  night.  If  the  attack  is  of 
much  severity  and  of  long  standing,  there  may  be  some  wasting 
of  the  muscles. 

Treatment.  Sciatica  is  one  of  the  most  troublesome  neuralgias 
to  treat.  For  the  malarial  cases,  large  doses  of  quinine,  pre- 
ceded by  a  mercurial  cathartic,  and,  if  possible,  removal  from 
the  region.  Some  cases  will  not  recover  while  they  remain  in 
the  malarious  district.  In  those  cases  where  there  is  a  generally 
defective  nutrition,  this  should  be  restored,  if  possible,  by  tonics, 
cod-liver  oil,  milk,  cream,  etc.,  attention  to  the  assimilation  and 


NEURALGIA.  49 

secretions.  In  the  syphilitic  cases  large  doses  of  potass,  iodide. 
In  the  rheumatic  cases  fall  doses  of  soda  salicylate  often  o-ive 
immediate  results  ;  alkalies  and  colchicum  are  also  beneficial. 
There  should  be  absolute  rest  to  the  hmb.  Galvanism  often 
gives  good  results,  relieving  the  pain  ;  some  think  it  is  curative. 
The  actual  cautery  and  blisters  often  give  good  results.  Sprays 
of  methyline  have  been  used  in  recent  years  with  some  success. 
In  some  obstinate  cases  stretching  the  nerve  has  been  successful. 
To  relieve  pain  phenacetin  in  full  doses  may  be  tried.  Morpliia 
may  have  to  be  used. 

Herpes  Zoster 

Is  the  name  given  to  an  erythematous  and  papular  eruption 
which  comes  on  as  a  trophic  symptom  in  neuralgia.  The 
eruption  is  always  along  the  course  of  a  nerve  or  its  branches. 
It  is  preceded  by  the  stabbing  pains  and  by  a  tingling,  itching 
sensation  along  the  course  of  the  nerve  or  its  branches.  The 
eruption  is  very  frequently  in  patches.  The  pustules  may  sup- 
purate, and  when  they  are  large  leave  scars ;  or  they  may 
simply  dry  up  and  disaj^pear  without  any  after-symptoms.  At 
times  when  it  occurs  in  elderly  persons  there  is  a  painful  neu- 
ralgia in  the  nerve  after  the  subsidence  of  the  eruption  and  it 
may  last  for  years,  indicating  probably  a  serious  change  in  the 
nerve.  It  may  be  found  in  association  with  neuralgia  of  almost 
any  nerve — the  fifth,  the  intercostals,  those  of  the  lumbar  and 
sacral  plexus.  When  it  is  in  the  fifth  nerve  it  is  the  supraorbital 
branches  that  are  its  seat,  and  if  the  ophthalmic  branches  are 
involved  there  is  danger  of  trophic  disturbances  of  the  cornea. 
It  is  sometimes  apparently  due  to  epidemic  influences. 

Bibliography.—^.  Weir  Mitchell,  Injuries  of  Nerves,  1864, 
2d  edition,  1872.— Bowlby,  Injuries  and  Diseases  of  :N'erves, 
1890.— The  Various  Works  and  Encyclopaedias  on  Surgery.— 
Buzzard,  Some  Forms  of  Paralysis  Dependent  upon  Peripheral 
Keuritis,  London  Lancet,  1885,  and  Monograph.— Starr,  Mul- 
tiple ISTeuritis  and  its  Relations  to  Certain  Peripheral  :N'eurosis, 
New  York  Medical  Journal,  1887.— Miles,  Diseases  of  the 
4 


50  NERVOUS    DISEASES    AND    INSANITY. 

Peripheral  Kerves,  Pepper's  System  of  Medicine.— J.  J.  Put- 
nam, Case  of  Acute  Fatal  Multiple  Neuritis  of  Infectious  Origin, 
Journal  of  Nervous  and  Mental  Disease,  1890  ;  Ross,  Medical 
Chronicle,  1889  and  1890.— J.  J.  Putnam,  Neuralgia,  Pepper's 
System  of  Medicine. — Erb,  Ziemssen's  Cyclopaedia  of  Medicine, 
vol.  IX.,  Am.  Trans. — Taylor,  A  Contribution  to  the  Study  of 
Multiple  Neuritis  of  Syphilitic  Origin,  New  York  Medical  Jour- 
nal, 1890. 


INFLAMMATORY    DISEASES    OF    SPINAL    CORD.      51 


SECTION  II. 
DISEASES  OF  THE  SPIKAL  CORD. 


CHAPTER  1. 
The  Acute  Inflammatory  (?)  Diseases  of  the  Spinal  Cord. 

Acute  Spinal  Meningitis. 

( Lepto -meningitis. ) 

Acute  meningitis  confined  to  the  spinal  meninges  is  a  very 
uncommon  condition. 

Etiology.  As  predisposing  causes  :  the  tul)erculRr  and  scrofu- 
lous diathesis  ;  weakly  constitutions  ;  residence  in  unhealtliy, 
damp  places,  with  poor  food  and  clothing.  It  occurs  after  rheu- 
matism and  pneumonia.  It  may  occur  as  a  complication  in 
localized  disease  of  the  spinal  colunm.  such  as  caries  or  tumors. 

Symptoms.  There  is  a  feeling  of  heaviness,  and  lack  of  de- 
sire to  move  about,  but  a  restlessness  ;  pains  in  the  back  soon 
follow,  with  some  elevation  of  temperature  ;  irregular  in  type  ; 
pains  radiating  along  the  ilerve-trunks,  which  may  be  severe  or 
slight ;  crami)S  in  the  muscles  of  the  extremities,  so  that  the 
legs  may  be  drawn  up  or  kept  in  some  unnatural  position  ;  the 
reflexes  are  increased  ;  there  is  hyperesthesia  of  the  skin  ;  re- 
tention of  urine  ma}'  be  present ;  the  bowels  are  constipated. 
If  the  disease  increases,  there  will  be  opisthotonos  ;  disturbances 
of  respiration,  and  tlie.  muscular  spasm  gives  place  to  paralysis 
in  some  muscular  groups  ;  in  place  of  the  hypergesthesia,  we  find 
anaesthesia  more  or  less  marked. 

The  medulla  may  become  involved  ;  paralysis  of  muscles  of 
the  eye,  and  disturbances  of  respiration,  and  coma,  followed  by 
death.     There  are  often  periods  of  remission. 

Pathological  Anatomy.  (See  Meningitis.  Diseases  of  the 
Brain.) 


62  NERVOUS    DISEASES    AND    INSANITY. 

Myelitis. 

(Inflammation  of  the  Spinal  Cord,  Acute,  Subacute, 
and  Chronic.) 

Acute,  subacute,  and  chronic  has  reference  only  to  the  length 
of  time  the  symptoms  are  in  developing ;  it  is  a  more  or  less 
active  inflammatory  process.  It  may  involve  only  portions  of 
the  cord  ;  to  a  certain  extent  functionally  distinct  tracts  ;  sys- 
tematized lesions,  as  in  acute  myelitis  of  the  anterior  horns  ; 
or  it  may  be  more  or  less  difiuse,  involving  gray  and  white 
matter  without  regard  to  regions.  It  sometimes  affects  the  cord 
all  through  transversely,  involving  white  and  gray  matter  for  a 
limited  distance  horizontally— transverse  myelitis  — at  other 
times  it  may  affect  large  portions  of  the  cord— diffuse  myelitis. 
Inflammation  of  the  cord  occurs  under  a  number  of  circum- 
stances ;  in  all  cases  of  compression  of  the  cord— compression 
myelitis — but,  as  it  has  some  features  of  its  own,  it  is  treated 
separately.  It  occurs  as  a  somewhat  chronic  process  in  dissemi- 
nated sclerosis.  It  may  be  set  up  at  any  time  in  a  spinal  cord, 
the  seat  of  the  degenerative  diseases  —  locomotor  ataxia,  for 
instance. 

Etiology.  It  is  said  to  be  caused  by  cold,  damp,  and  expo- 
sure, over-exertion,  falls,  concussion,  syphilis  ;  after  typhoid, 
variola,  and  other  diseases,  which  impair  the  vitality  of  the 
system.  It  follows  puerperal  diseases  and  the  puerperal  state. 
Poisoning  by  lead,  arsenic,  etc. 

Symptoms.  These  vary  according  to  the  extent  of  the  lesion. 
Weakness,  which  may  begin  in  one  leg  and  extend  to  the  other, 
causing  difficulty  in  walking,  weakness,  and  pain  in  back, 
numbness  in  legs,  tingling,  pricking  at  times ;  the  limbs  may 
tremble,  and  there  may  be  some  passing  cramps  in  the  mus- 
cles. These  symptoms  progress  until  the  person  becomes  help- 
less ;  is  confined  to  bed  ;  the  legs  become  weaker  until  they 
cannot  be  moved.  If  the  disease  progresses,  the  bladder  be- 
comes involved.  At  first  there  may  be  retention  of  urine  ;  later, 
it  dribbles  away,  and  the  bowels  may  act  involuntarily  ;  the 
numbness  increases  to  anaesthesia,  more  or  less  great,  according 


INFLAMMATORY    DISEASES    OF    SPINAL    CORD.       53 

to  the  severity  and  extent  of  the  inflammation  ;  a  band-like 
feeling  is  felt  across  the  body  ;  if  at  first  low  down,  at  or  below 
the  umbilicus,  as  the  inflammation  extends  upwards,  the  girdle 
sensation  goes  higher  and  higher,  and  it  will  be  found  that  the 
anaesthesia  follows  pretty  closely  after  it.  This  band-like  sensa- 
tion indicates  the  line  of  the  inflammation  ;  all  the  parts  of  the 
body  below  are  more  or  less  anaesthetic  and  paralyzed.  Trophic 
disorders  begin  to  appear ;  bullae  form  on  the  feet  and  toes ; 
cystitis  is  set  up  ;  the  urine  becomes  ammoniacal,  and  is  loaded 
with  mucus  ;  the  unfortunate  person  aches  unless  the  anaethe- 
sia  is  great,  which  it  only  rarely  is  ;  bed-sores  form,  and  in  men 
the  penis  may  slough.  The  facial  expression  is  pale,  anxious, 
and  distressed.  There  may  be  some  elevation  of  temperature. 
As  the  disease  extends  upwards  the  respiration  is  involved,  and 
death  occurs  by  accumulation  of  mucus  in  the  throat  and  lun^s 
and  involvement  of  tlie  medulla.  A  case  with  these  cHuical 
features  may  run  a  course  of  six  months  or  more  before  death 
occurs  ;  others  die  in  two  or  three  months.  The  middle  and 
lower  dorsal  region  is  the  most  frequent  seat  of  this  disease. 
The  seat  of  the  myelitis  will  somewhat  modify  the  symptoms  ; 
its  location  can  be  fairly  accurately  determined  by  a  study  of 
the  symptoms  in  each  case  :  the  motor  disturbances  ;  the  sen- 
sory, the  reflexes,  etc.,  with  the  aid  of  the  diagram  of  the 
spinal  cord  in  its  relation  to  the  vertebral  column,  and  the  table 
of  Starr.     (Fig.  28.) 

Diagnosis.  The  somewhat  rapid  onset  of  the  symptoms  as  a 
motor  weakness  associated  with  the  decided  sensory  symptoms, 
anaesthesia,  if  the  disease  progresses,  the  appearance  of  bed- 
sores, fever,  often  moderate,  paralysis  of  bladder,  etc. 

Prognosis.  In  the  severe  cases  with  rapidly  progressing 
symptoms,  unfavorable  as  a  rule  ;  some  cases  of  transverse 
myelitis  recover.  I  have  seen  them  recover  when  there  were 
decided  anaesthesia  and  almost  complete  paralysis. 

Treatment.  Ergot  often  appears  to  be  of  service  ;  cupping  to 
the  spine,  if  there  is  good  reason  for  thinking  it  due  to  syphilis ; 
iodide  potass.  The  urine  should  be  drawn  off,  and  if  there  is  a 
tendency  to  cystitis,  the  bladder  should  be  washed  out  every  day 
with  a  solution  of  boracic  acid. 


54  NERVOUS    DISEASES    AND    INSANITY. 

The  bed-sores  can  be  treated  according  to  Brown-Seqiiard's 
method  of  alternate  applications  of  heat  and  cold — ice  and  hot 
poultices.  One  of  the  best  applications,  if  not  the  best,  for  these 
bed  sores  is  a  mixture  of  iodoform  in  Peruvian  balsam  and 
absorbent  cotton  over  it.  The  person  should  be  kept  clean,  and 
pressure  on  the  paralyzed  parts  prevented  as  much  as  possible  ; 
a  water  or  air  bed  may  be  found  necessary. 

Bihliogra^Tiy.—^.  G.  Webber,  Journal  of  Nervous  and  Mental 

Disease,  1880. 

Compression  Myelitis. 

Tins  occurs  from  pressure  on  the  spinal  cord  by  fractures  of  the 
spine,  caries  of  the  spine,  tumors  of  the  spine,  or  developed 
inside  the  spinal  canal. 

The  onset  of  the  symptoms  may  be  either  sudden  or  gradual, 
according  to  the  cause  of  compression.  In  fracture  it  is  sudden 
as  a  rule  ;  in  tumors  and  caries,  gradual. 

Symptoms.  There  is  a  grouping  of  symptoms  common  to 
these  cases  of  compression.  Paralysis  more  or  less  complete  in 
all  the  parts  below  the  seat  of  disease.  Irritation  to  the  nerves 
at  the  seat  of  disease  as  shown  by  pains,  constant  or  darting, 
along  the  course  of  the  nerves  in  the  immediate  neighborhood 
of  the  disease.  Cramps  in  the  muscles  supplied  by  these  nerves. 
And  there  maybe  anaesthesia  in  their  distribution,  if  the  pressure 
is  sufficiently  great  to  injure  them.  If  the  pressure  is  very  great, 
so  as  to  compress  the  cord  very  much  or  cut  it  across,  then 
anaesthesia  may  be  more  or  less  complete  in  all  the  parts  below ; 
the  functions  of  the  bladder  are  disturbed  ;  the  urine  has  to  be 
drawn  off,  it  dribbles  awny.  There  are  pain  and  aching  in  the 
hips  and  legs.  Trophic  disorders  soon  appear.  If  the  compres- 
sion is  decided  and  sudden,  they  come  on  early  and  rapidly.  If 
the  cause  of  compression  is  slowly  operative,  they  come  on  later 
and  progressively.  They  consist  in  the  formation  of  bullse  and 
ulcerations  on  the  paralyzed  extremities  and  bed-sores  with  cys- 
titis. If  the  disease  is  in  the  mid-dorsal  region,  what  has  been 
called  "spinal  epilepsy"  occurs.    It  is  a  spasmodic  twitching  of 


INFLAMMATORY    DISEASES    OF    SPINAL    CORD.       55 

the  lower  extremities  ;  muscular  wasting  may  be  present.  The 
paralyzed  parts  look  bluish.  There  may  be  a  moderate  amount 
of  elevation  of  temperature.  The  pulse  rate  is  increased,  and  is 
usually  out  of  proportion  to  the  elevation  of  temperature. 
There  is  frequently  vomiting.  The  reflexes  are  abolished  at  the 
seat  of  compression.  If  the  pressure  is  high  up,  there  is  in- 
crease of  the  reflexes  in  the  parts  below. 

In  fracture  of  the  spine  the  symptoms  appear  suddenly  ;  the 
most  common  seat  of  fracture  is  at  the  fifth  and  sixth  cervical 
and  the  last  dorsal  and  fir.st  lumbar  vertebra? ;  but  it  may  occur 
anywhere. 

The  fractured  bones  are  driven  in  upon  the  spinal  cord,  com- 
pressing it  or  cutting  it  off  entirely.  Occasionally,  the  com- 
pression does  not  occur  at  once,  but  later.  Motion  causes  a 
displacement  of  a  portion  of  the  fractured  bone  to  encroach 
upon  the  spinal  canal. 

In  caries  of  the  spine  there  are  frequent  symptoms  of  irritation 
of  the  nerves  passing  off  from  the  seat  of  disease  with,  perhaps, 
some  paresis  and  muscular  wasting  of  the  parts  supplied  by 
those  nerves  ;  and  paralysis  may  come  on  slowly  or  suddenly. 
The  paralysis  in  these  cases  comes  on  in  two  w^nys— either  from 
breaking  down  of  the  carious  bones  and  displacem.ent  of  the 
fragments,  or  by  the  accumulation  of  pus  at  the  seat  of  caries, 
which  gradually  presses  the  dura  in  upon  the  cord.  There  are 
cases  in  which  the  paralysis  will  come  on  suddenly  in  an  old 
case  of  caries,  and  a  good  deal  of  improvement  may  occur  in 
the  paralysis  afterwards.  A  careful  and  frequent  examination 
of  the  spine  in  the  early  stages  will  reveal  the  presence  of  the 
diseased  bone.  In  case  of  tumor  the  symptoms  come  on  gradu- 
ally, and  there  are  many  more  irritation  symptoms. 

Pathological  Anatomy.  The  most  common  form  of  tumor  to 
develop  in  the  spinal  canal  is  syphiloma,  sarcoma,  and  myxo- 
mata.  Multiple  tumors  are  sometimes  found  on  the  nerve-roots. 
They  are  usually  sarcomata,  and  develop  in  the  membranes  and 
sheaths  around  the  nerves. 

The  changes  which  take  place  in  the  cord  vary.  In  the  im- 
mediate vicinity  of  the  compression,  and  at  an  early  date,  the 
cord  is  swollen,  the  axis  cylinders  are  swollen,  the  mveline  is 


5t)  NERVOUS    DISEASES    AND    INSANITY. 

broken  up,  there  are  great  vascularity  and  distention  of  the 
bloodvessels,  there  may  be  some  spider-cells ;  granular  corpuscles 
are  always  found  in  the  fresh  state,  later  more  or  less  wasting 
of  the  spinal  cord  occurs.  Above  and  below  the  seat  of  injury 
secondary  degenerations  occur. 

Treatment.  Depends  upon  the  nature  of  the  compression  ; 
they  are  surgical  cases,  if  the  compression  is  due  to  caries  or 
fracture.  In  cases  of  tumor  the  question  of  surgical  interference 
must  be  considered.  For  its  indications  consult  Thorburn, 
"■  Surgery  of  the  Spinal  Cord." 


n 


Acute  Ascending  Paralysis. 

(Landry's  Paralysis.) 

Etiology.  It  is  supposed  to  follow  exposure  to  damp  and  cold. 
It  is  known  to  follow  typhus  and  typhoid  fever,  variola  and 
splenic  fever.  It  is  believed  by  many  to  depend  upon  toxic 
infection.     Syphilis  is  supposed  to  be  a  cause. 

Symptoms.  There  may  be  premonitory  symptoms,  such  as 
aching  and  soreness,  with  tingling  in  the  parts  ;  headache  and 
backache  ;  or  it  may  appear  during  the  course  or  at  the  onset 
of  some  other  disease.  The  first  definite  symptom  is  usually 
a  weakness  in  both  legs,  which  increases  rapidly  to  complete 
paralysis,  sometimes  in  a  few  hours  ;  it  soon  extends  to  the 
arms  ;  as  the  lesion  extends  up  to  the  medulla,  there  occurs 
paralysis  of  the  diaphragm  and  neck  muscles  ;  there  is  difficulty 
in  swallowing  and  speaking,  owing  to  paralysis  of  the  muscles 
of  speech  and  deglutition.  The  extremities  are  flaccid  and 
powerless  ;  there  is  no  muscular  atrophy  ;  there  are  no  altera- 
tions in  the  electrical  reactions  ;  the  reflexes  are  lost ;  there  are 
sensations  of  tingling,  but  no  loss  of  tactile  sensibility  as  a  rule. 
There  are  no  bladder  or  rectal  symptoms ;  no  bed-sores  ;  the 
mind  is  not  disturbed.  It  usually  runs  a  rapid  course  of  from 
three  to  ten  days  in  death  by  arrest  of  respiration,  owing  to  the 
implication  of  the  medulla  oblongata. 

Pathology.  The  changes  in  the  spinal  cord  which  give  rise  to 
this  rapidly  increasing  paralysis  are  not  fully  made  out.     In  fact. 


INFLAMMATORY    DISEASES    OF    SPINAL    CORD.       57 

up  to  within  a  few  years,  observations  made  with  great  care 
have  revealed  no  lesions  of  the  cord  ;  but  more  recently  Immer- 
man  found  in  a  case  no  changes  in  the  central  nervous  system 
or  in  the  peripheral  nerves  macroscopicall}^  Microscopically  the 
anterior  horns  were  found  to  be  the  seat  of  an  intense  vascular 
injection  and  degeneration  changes  in  the  ganglion  cells.  The 
following  year  (1880),  Soudeykein  found  diminution  in  the  size 
of  the  anterior  horns  ;  the  large  cells  had  lost  their  processes, 
their  shape  was  altered,  and  they  had  undergone  granular 
changes ;  the  central  canal  was  obliterated  and  surrounded  by 
a  mass  of  granular  cellular  elements.  This  year  (1891),  Klebs, 
in  the  study  of  a  case,  has  found  that  the  central  arteries  of  the 
cord  are  the  seat  of  hyaline  thrombi ;  the  thrombosed  area  being 
the  central  gray  tube  on  each  side  of  the  central  canal ;  trans- 
verse and  longitudinal  sections  showed  vessels  plugged  with 
hyaline  thrombi,  which  were  directed  towards  the  anterior 
horns  ;  in  the  region  of  these  blocked  vessels  minute  hemor- 
rhages (visible  only  with  the  microscope)  were  found,  in  which 
the  blood-cells  were  fixed  and  stained  ;  the  greatly  distended 
perivascular  spaces  were  filled  with  a  retiform  coagulated  sub- 
stance in  which  were  imbedded  a  few  spheroidal  cells  possessing 
a  single  large  nucleus.  Klebs  believes  that  Landry's  paralysis 
is  nothing  more  than  an  acute  myelitis  of  the  anterior  horns, 
very  rapid  in  its  progress  and  termination.  In  a  case  recently 
reported  by  Hun  no  lesions  were  found  adequate  to  account  for 
the  symptoms  after  a  careful  microscopic  examination  hy  Dr.  Ira 
Yan  Gieson,  and  he  was  unable  to  confirm  the  finding  of  hyaline 
thrombi  of  the  central  arteries,  as  reported  by  Klebs.  It  may  be 
fairly  said  that  at  the  present  time  nothing  definite  is  known  of 
the  pathological  changes  in  this  disease. 

Prognosis.  Unfavorable  ;  it  is  a  rapidly  fatal  disease.  A  few 
cases  are  reported  as  recovered. 

Treatment.  Up  to  this  time  no  treatment  has  been  of  much 
seryice. 

Bihliograjyhy. — Henry  Hun,  The  Pathology  of  Acute  Ascend- 
ing Paralysis,  ]^ew  York  Medical  Journal,  May  30, 1891.  Addi- 
tional references  will  be  found  in  this  article. 


58  NERVOUS    DISEASES    AND    INSANITY. 

Acute  Myelitis  of  the  Anterior  Horns  of  the 

Spinal  Cord. 

(Infantile  Spinal  Paralysis.     Acute  Poliomyelitis  Anterior.) 

Etiology.  It  occurs  in  children  during  the  first  ten  years  of 
their  life,  but  is  most  common  from  birth  up  to  three  years  of 
age.  Boys  are  more  often  aflected  than  girls  ;  but  G-owers 
thinks  this  is  only  so  in  those  cases  which  occur  under  two 
years  of  age.  Sinkler,  of  Philadelphia,  first  pointed  out  that 
the  disease  was  very  much  more  frequent  in  summer  than  in 
winter,  and  that  the  largest  number  occur  from  May  to  Sep- 
tember. Cold  has  always  been  assigned  as  a  cause  ;  but  Sink- 
ler's  observations  throw  doubt  upon  this.  The  children  are 
often  apparently  well  when  they  are  suddenly  attacked  ;  it  may 
occur  after  diarrhcea,  some  of  the  eruptive  or  malarial  fevers. 

Symptoms.  The  onset  is  usually  sudden.  As  premonitory 
symptoms  there  maybe  some  languor  and  irritability.  There  is 
usually  more  or  less  fever  of  short  duration.  The  attack  may  be 
ushered  in  by  a  convulsion  ;  or  the  child  may  be  j)ut  to  bed  ap- 
parently quite  well ;  it  is  restless  during  the  night,  and  in  the 
morning  it  is  found  to  be  paralyzed  in  some  of  its  extremities. 
The  two  lower  extremities  are  the  most  commonly  afifected.  At 
first  there  is  a  good  deal  of  sensitiveness  about  the  paralyzed 
extremities  ;  if  they  are  handled,  the  child  screams  ;  this  lasts 
a  few  hours  or  a  few  days,  and  subsides.  After  a  week  or  so, 
some  of  the  paralyzed  muscles  may  recover,  leaving  others 
permanently  weakened.  The  distributi(m  of  the  paralysis  is 
variable  ;  the  lower  extremities  are  the  most  frequently  affected, 
one  or  both  legs  ;  the  upper  extremities,  the  muscles  of  the  neck 
and  back  may  be  paralyzed  ;  or  it  may  be  hemiplegic  in  distri- 
bution ;  but  this  is  rare.  There  are  no  sensory  disorders.  Ke- 
flex action  is  lost  in  the  paralyzed  parts.  There  are  no  rectal  or 
vesical  disturbances.  The  parts  which  remain  paralyzed  soon 
show  trophic  disturbances.  The  muscles  begin  to  atropine,  the 
parts  are  bluish  and  cold,  the  circulation  is  defective,  chilblains 
form  easily ;  whenever  there  is  any  undue  pressure  from  a  shoe 
or  brace,  sores  form.     The  muscular  atrophy  becomes  extreme 


INFLAMMATORY    DISEASES    OF    SPINAL    CORD.       59 

in  some  cases  ;  as  a  consequence  deformities  arise.  Talipes 
equines  and  varus  are  the  most  common.  Tlicse  deformities 
are  brouglit  about  by  one  of  tliree  causes,  but  most  probably  by 
a  combination  of  some  of  these  conditions  :  1.  It  is  believed  by 
some  that  they  are  due  to  the  predominant  action  of  the  healthy 
muscles.  2,  Yolkman  believes  it  is  due  to  the  weight  of  the 
limb  itself.  3.  That  the  healthy  muscles  are  constantly  short- 
ening, owing  to  the  absence  of  the  power  of  their  antagonistic 
muscles.  As  the  child  grows,  the  paralyzed  limb  does  not  de- 
velop in  keeping  with  the  healthy  one  ;  there  is  retarded  devel- 
opment. The  bones  are  shorter  and  smaller,  so  that  when  the 
child  grows  up  the  paralyzed  extremity  is  shorter  and  smaller 
than  the  others.  The  electrical  reactions  for  faradism  are  very 
much  diminished  or  lost ;  the  galvanic  reaction  varies  from  simple 
diminution  to  complete  reaction  of  degeneration,  or  even  entire 
absence  of  reaction. 

Pathological  Anatomy.  Autopsies  early  in  the  course  of  the 
disease  are  not  frequent.  In  such  cases  the  anterior  cornute 
corresponding  to  the  affected  parts  are  found  very  vascular,  the 
capillaries  are  distended,  and  there  are  minute  extravasations 
of  blood  in  the  gray  substance  ;  the  ganglion  cells  are  swollen, 
granular,  and  their  processes  indistinct ;  there  may  be  infiltra- 
tion of  leucocytes  to  a  moderate  degree.  In  autopsies  made 
many  years  after  the  onset  of  the  disease,  the  anterior  horn  is 
shrunken,  the  ganglion  cells  are  absent,  and  the  surrounding 
tissue  is  dense,  and  stains  more  sharply  with  carmine. 

Prognosis.  These  children  rarely  die  in  the  acute  stage  ; 
death  usually  occurs  years  after  of  some  other  disease.  Im- 
provement may  take  place  in  some  of  the  paralyzed  muscles 
after  a  number  of  weeks  ;  this  cannot  be  predicted.  Although 
some  improvement  may  occur,  I  have  never  known  one  of 
these  cases  to  get  well. 

Treatment.  Tonics,  cod-liver  oil,  attention  to  the  diet,  and 
general  hygienic  management,  sponging  with  cold  water,  etc. 
For  a  long  time  galvanism  has  been  used  on  these  paralyzed 
muscles.  I  have  seen  but  very  little  benefit  from  its  use.  If 
tried,  it  must  be  with  the  hope  of  keeping  the  paralyzed  muscles 
frf)m  wasting,  and  improving  the  condition  of  the  circulation 


60  NERVOUS    DISEASES    AND    INSANITY. 

and  nutrition  ;  but  in  this  you  will  often  be  disappointed.  Mas- 
sage may  be  of  service.  Later,  if  deformities  arise,  the  ortho- 
pedic surgeon  will  aid  you  by  dividing  the  tendons  and  placing 
the  limbs  in  a  comparatively  useful  position. 

Bibliography. — Dr.  E.  C.  Seguin,  Myelitis  of  the  Anterior 
Horns.  Monograph.— Dr.  Mary  Putnam  Jacobi,  Pepper's  Sys- 
tem of  Medicine. 

Acute  Myelitis  of  the  Anterior  Horns. 

(Acute  Spinal  Paralysis  in  the  Adult.) 

It  may  be  acute  or  subacute  in  its  onset  ;  it  has  a  very  great 
resemblance  to  acute  myelitis  of  the  anterior  horns  in  children  ; 
it  is  evidently  the  same  disease,  with  some  slight  modifications 
in  symptomatology. 

Etiology.  It  occurs  in  adults ;  so  far  as  is  known,  its  cause 
is  similar  to  that  operating  in  children. 

Symptoms.  The  onset  may  be  somewhat  sudden.  There  may 
be  some  elevation  of  temperature,  tingling  and  pricking  sensa- 
tions about  the  extremities,  with  a  feeling  of  numbness ;  some 
aching  in  the  back  ;  and  in  from  24  to  48  hours  paralysis,  more 
or  less  great,  comes  on,  or  it  may  develop  much  more  slowly. 
It  most  commonly  affects  all  extremities  ;  but  in  a  proportion 
of  cases  it  is  confined  to  the  lower  extremities— paraplegic. 
Rarely  the  face,  eyes,  tongue,  and  muscles  of  deglutition  are 
affected.  There  is  in  some  cases  a  very  slight  impairment 
of  tactile  sensation  at  first,  but  it  is  not  lasting.  Other  than 
this,  there  are  no  true  sensory  disorders  ;  there  are  no  disturb- 
ances of  the  functions  of  the  bladder  and  rectum  ;  the  para- 
lyzed muscles  may  present  fibrillary  contractions,  but  this  is  only 
observed  in  the  subacute  cases.  There  is  loss  of  faradic  reaction 
and  reaction  of  degeneration  to  galvanism.  There  may  be  some 
constriction  feeling  about  the  body  or  limbs.  There  is  quite  a 
marked  tendency  for  the  paralyzed  muscles  to  recover,  and  in 
a  large  proportion  of  the  acute  cases  recovery  is  complete  ;  but 
in  those  cases  where  all  the  muscles  do  not  recover,  muscular 
atrophy  occurs,  and  may  become  extreme,  giving  rise  to  contrac- 


INFLAMMATORY    DISEASES    OF    SPINAL    CORD. 

Fig.  11. 


61 


Acute  spinal  paralysis  of  the  adult ;  showing  the  atrophy,  deformities,  etc.,  in  the 
lower  extremities.     (After  Seguin.) 

ture  and  deformities.     The  circulation  is  poor  ;  the  extremities 
are  purplish  and  cold. 
Prognosis.    The  same  as  in  children. 


62  NERVOUS    DISEASES    AND    INSANITY. 

Diagnosis.  The  more  or  less  rapid  onset  of  motor  weakness, 
without  true  sensory  symptoms,  the  subsequent  atrophy  and  de- 
formities, absence  of  bladder  and  rectal  disorders,  disturbance  in 
the  electrical  reactions,  etc. 

Pathological  Anatomy.  Is  similar  to  that  of  acute  myelitis 
of  the  anterior  horns  in  children. 

Treatment.    Must  be  such  as  is  adopted  in  children. 

Bihliography.—^.  C.  Seguin,  Spinal  Paralysis.    (Monograph.) 


CHAPTER  11. 

The  Degenerative  Diseases  of  the  Spinal  Cord. 

Progressive  Muscular  Atrophy. 

(Chronic  Myelitis  of  the  Anterior  Horns  of  the  Spinal 

Cord.) 

It  attacks  males  oftener  than  females  ;  not  infrequently  devel- 
oping during  convalescence  from  some  acute  disease,  such  as 
measles,  acute  rheumatism,  typhoid  fever,  etc.  It  is  thought  to 
be  caused  by  cold,  excessive  physical  exertion,  injuries,  etc.,  but 
it  often  occurs  without  the  possibility  of  assigning  a  cause — ap- 
parently as  a  degenerative  process.  Heredity  is  said  by  Schultze 
(Sachs)  to  be  an  important  element  in  its  causation.- 

Symptoms.  It  begins  slowly,  as  a  weakness  in  the  upper  ex- 
tremity, usually,  and  more  frequently  in  the  right  hand  ;  there 
may  be  some  aching  in  the  hand.  Soon  the  muscles  of  the  hand 
are  found  wasting  away.  At  other  times  the  symptoms  come 
on  less  slowly,  with  aching  in  the  muscles  and  pains  ;  the  disease 
progresses  more  rapidly  and  the  atrophy  is  more  generalized. 
The  atrophy  extends  from  one  muscle  or  one  group  to  the 
other.  In  cases  where  the  shoulder  muscles  are  much  wasted, 
the  arms  hang  down  by  the  sides,  and  the  hands  have  a  flattened 
flabby  appearance.  In  some  cases  the  legs  are  involved  in  the 
disease,  but  the  atrophy  is  never  so  marked  as  in  the  upper  ex- 
tremities. As  the  disease  progresses  the  medulla  may  be  involved, 


DEGENERATIVE    DISEASES    OJb'    SPINAL    CORD.       G3 

when  we  have  in  addition  bulbar  paralysis,  the  tongue  is  atro- 
phied, it  presents  a  shrivelled  shrunken  appearance,  the  muscles 
of  the  face  and  deglutition  are  weak,  there  is  indistinctness  in 
speaking,  and  later  much  difficulty  in  swallowing,  owing  to  the 
paresis  of  the  muscles  of  deglutition.  In  extreme  cases  much 
distress  is  caused  by  fluids  passing  up  through  the  posterior 
nares   and  out  of  the  nose. 

Fibrillary  contractions  are  constant  in  these  atrophied  muscles, 
and  especially  in  the  tongue.  The  tendon  reflex  is  lost  in  all 
those  cases  in  which  the  dorso-lumbar  cord  is  involved.  The 
faradic  and  galvanic  reactions  may  be  simply  diminished.  There 
are  no  sensory  disorders  in  this  disease ;  no  bladder  or  rectal 
disturbance  :  the  parts  are  cold  and  the  circulation  impaired. 

Pathological  Anatomy.  Atrophy,  granular  pigmentation,  and 
disappearance  of  the  ganglion  cells  of  the  anterior  horns.  There 
is  some  thickening  and  change  in  the  neuroglia  ;  increase  in  the 
size  of  the  bloodvessels  ;  in  fresh  sections  of  the  cord  granular 
corpuscles  may  be  found.  The  anterior  horns  later  become 
shrunken  ;  the  anterior  roots  are  somewhat  atrophied.  The 
disease  is  believed  to  begin  in  the  anterior  horns  and  its  large 
ganglion  cells  ;  the  anterior  roots  are  diseased  secondarily.  The 
anterior  horns  and  more  especially  its  ganglion  cells  are  the 
trophic  centres  for  the  anterior  roots,  motor  nerves,  and  muscles. 
The  disease  of  the  anterior  roots  and  the  muscular  atrophy  are 
in  relation  to  the  extent  of  the  lesion  in  the  anterior  horn  ;  the 
slow  and  gradual  disease  of  the  ganglion  cells  explains  the  slowly 
progressing  muscular  atrophy,  and  as  one  portion  after  another 
of  the  spinal  cord  becomes  affected  the  muscles  of  which  it  is 
the  trophic  centre  waste. 

Prognosis.  Unfavorable.  In  some  cases  the  progress  of  the 
disease  is  of  many  years'  duration  ;  in  others  it  is  more  rapid, 
one,  two,  or  three  years  ;  and  if  bulbar  symptoms  are  added 
death  may  occur  sooner. 

Treatment.  No  treatment  has  exercised  much  influence  over 
the  progress  of  this  disease.  Tonics,  cod-liver  oil,  and  galvanism 
are  indicated.  Avoidance  of  the  use  of  the  muscles  appears  to 
have  some  influence  in  retarding  the  atrophy  and  prolonging 
the  miserable  existence  of  the  person. 


64  NERVOUS    DISEASES    AND    INSANITY. 

Progressive  Muscular  Atrophy. 

(The  Peroneal  Form  of  Herbert  Tooth.) 

This  disease  is  described  here,  although  at  the  present  time 
its  exact  place  in  the  two  large  groups  of  muscular  atrophy  is 
not  certain,  as  no  pathological  findings  have  shown  if  this  be  a 
disease  depending  upon  a  nervous  or  a  muscular  lesion  ;  but 
there  are  many  indications  which  justify  its  being  placed,  for  the 
present,  at  least,  with  the  muscular  atrophies  of  nervous  origin. 

That  it  is  an  hereditary  disease  has  been  well  established.  It 
was  first  described  by  Charcot  and  Marie  in  1886,  and  simul- 
taneously by  Herbert  Tooth  in  England,  and  recently  by  B. 
Sachs  in  this  country.  A  case  of  this  disease,  of  which  I  have 
notes,  was  observed  by  me  in  1876.  I  recognized  it  as  different 
from  the  ordinary  type  of  progressive  muscular  atrophy.  It 
was  in  a  young  man  aged  18,  who  had  two  younger  brothers 
affected  in  the  same  way  ;  it  began  at  a  very  early  age  in  each 
of  them.  It  may  begin  from  very  early  childhood  to  20  years 
of  age,  and  occasionally  later.  It  begins  simultaneousl}^  in  both 
lower  extremities  as  a  progressive  weakness  and  difficulty  in 
using  them  ;  the  muscles  of  the  foot  and  leg  begin  to  atrophy. 
It  is  a  wasting  of  individual  muscles,  and  progresses  slow^ly  ; 
sooner  or  later  deformities  arise  due  to  paresis  and  atrophy  of  the 
muscles  of  the  anterior  tibial  and  peroneal  groups.  This  atrophy 
may  be  confined  to  the  lower  extremities,  or  it  may  extend  to 
the  upper  extremities,  and  there  may  be  the  deformity  of  the 
hand  known  as  "  main  en  griffe."  In  a  case  of  Sachs  there  was 
atrophy  of  the  infraspinatus.  In  a  case  recently  observed  by 
me  the  hands  only  are  at  present  affected.  There  are  no  sensory 
rectal  or  vesical  symptoms.  The  tendon  reflexes  are  present 
until  a  very  late  date.  There  are  vasomotor  disorders  similar 
to  what  are  seen  in  acute  poliomyelitis  anterior.  There  may 
be  partial  or  complete  reaction  of  degeneration. 

Prognosis.  The  condition  progresses  slowly  ;  death  is  caused 
by  some  intercurrent  disease  which  may  arise. 

Treatment.  The  same  as  that  indicated  for  acute  polio- 
myelitis anterior. 


DEGENEllATIVE    DISEASES    OF    SPINAL    CORD.       65 

Bibliogra^jhy. — Charcot  and  Marie,  Rev.  de  M6decine,  1886. — 
Herbert  Tooth,  Brain,  1888  ;  and  Thesis,  1886.— B.  Sachs,  Brain, 
1888,  N.  Y.  Medical  Journal,  1888. 


Lateral  Amyotrophic  Sclerosis. 

This  was  for  a  long  time  confounded  with  progressive  muscular 
atrophy  until  Prof.  Charcot  pointed  out  the  distinctive  features. 

Etiology.  It  occurs  chiefly  between  30  and  50  years  of  age  ; 
men  are  most  frequently  affected.  Very  little  is  known  as  to 
its  causation. 

Symptoms.  It  usually  begins  in  the  upper  extremities,  but 
almost  simultaneously  in  the  lower  (the  majority  of  the  cases 
I  have  seen  began  in  the  lower  extremities),  as  a  difficulty  in 
motion.  There  is  a  certain  amount  of  weakness  in  the  members  ; 
even  at  this  early  stage  the  muscles  are  somewhat  wasted  ;  it  is 
not  in  individual,  or  groups  of  muscles,  as  in  the  common  type 
of  progressive  muscular  atrophy,  but  is  a  more  or  less  general 
wasting,  an  atrophy  en  masse,  as  Prof.  Charcot  says.  This  mus- 
cular w^asting  extends  rapidly  to  the  shoulders,  neck,  and  chest, 
with  paresis,  out  of  all  proportion  to  the  muscular  wasting. 
Soon  the  lower  extremities  show  evidence  of  atrophy,  but  it  is 
never  so  marked  as  in  the  upper  extremities.  The  walk  is 
spastic;  stiff;  the  feet  are  not  lifted  from  the  ground,  but 
dragged  and  shuffled  along  ;  the  toes  scrape  the  ground  ;  the 
knees  are  stiff,  and  the  muscles  rigid.  As  the  disease  pro- 
gresses the  extremities  become  quite  useless  and  stiff;  contrac- 
ture is  more  or  less  marked — in  some  cases  it  is  very  slight,  in- 
deed—and when  the  muscular  atrophy  is  extreme,  ma}'  disappear 
entirely.  The  reflexes  everywhere  are  exaggerated.  As  the 
disease  progresses  the  medulla  soon  becomes  involved,  and  we 
have  all  the  symptoms  of  bulbar  paralysis— paresis  of  the 
muscles  of  the  face  and  deglutition,  atrophy  of  the  tongue,  diffi- 
culty in  speaking  and  swallowing,  and  in  the  advanced  stages 
there  is  great  danger  of  food  passing  into  the  tracliea.  There 
are  no  sensory  disorders,  rectal,  or  vesical  disturbances  in  this 
disease. 


Q6  NERVOUS    DISEASES    AND    INSANITY. 

Fig.  12. 


W.— Paresis ;  muscular  atrophy ;  exaggerated  reflexes  ;  slight  contracture  in 
hands  and  legs.  Shows  peculiar  attitude  of  hands.  (Drawn  from  a  photograph  by 
Dr.  Bristow.) 

Prognosis.  Unfavorable.  Death  takes  place  in  two  or  three 
years  after  the   onset  of   the  disease  from    paralysis  of  the 


DEGENERATIVE    DISEASES    OF    SPINAL    CORD 


6T 


respiratory  centre,  or  from  exhaustion  due  to  the  inability  to 
take  sufficient  food,  and  from  difficulties  of  respiration  conse- 
quent upon  the  atrophy  of  the  respiratory  muscles  and  the 
accumulation  of  mucus  in  the  lungs. 

Diagnosis.  The  association  of  motor  weakness  with  nmscular 
atrophy  and  exaggerated  reflexes  ;  the  early  appearance  of  bull^ar 
symptoms  ;  the  absence  of  sensory,  bladder,  and  rectal  disorders. 

Fig.  13. 


Sclerosis  of  the  lateral  columns  in  a  case  of  lateral  amyotrophic  sclerosis. 

(Personal  case.) 

Pathology.  The  lesion  is  almost  always  strictly  confined  to 
the  anterior  horns  and  the  lateral  columns.  In  the  anterior 
horns  the  changes  are  similar  to  those  found  in  progressive 
muscular  atrophy,  gradual  wasting,  pigmentation,  and  absorp- 
tion of  the  large  ganglion  cells  ;  sclerosis  in  the  lateral  columns. 

Bibliography. — Charcot,  Diseases  of  the  oSTervous  System. — 
J.  C.  Shaw,  Journal  of  Nervous  and  Menial  Disease,  1879. — 
Beevor,  Brain,  1882  and  1886.  — Ormerod,  Brain,  1886. 


Syringo  Myelia. 

For  a  long  time  it  had  been  observed  at  autopsies  that  there 
were  in  some  cases  cavities  in  the  spinal  cord,  but  the  fact  was 
known  only  as  a  pathological  curiosity.  Olivier,  in  1827,  first 
used  the  name  syringo  myelia  ;  he  did  not  believe  in  a  central 
canal  in  the  spinal  cord,  and  looked  upon  these  cavities  as  an  ar- 
rest of  development.  Later,  it  was  clearly  proved  that  there  was 
a  central  canal  in  the  spinal  cord.  Soon  observations  were  re- 
corded of  an  abnormal  dilatation  of  the  central  canal,  and  they 


68  NERVOUS    DISEASES    AND    INSANITY. 

were  looked  upon  as  arrests  of  development  and  described  under 
the  name  of  hydromyelia.  Hollopeau,  later,  studied  some  con- 
ditions, somewhat  analogous,  under  the  name  diffuse  pen- 
ependjjmal  sclerosis.  In  1869  Grimm  showed  that  the  old 
syringo  myelia,  hyromyelia,  and  peri-ependymal  myelitis  was 
really  due  to  a  neoplasm  developed  in  the  centre  of  the  cord. 
This  view  was  adopted  by  Simon,  Westphal,  and  Lej^den  ;  but 
later  the  work  of  Schultze  (1882)  and  Kahler  (1881)  showed  that 
this  pathological  lesion  was  associated  with  a  certain  grouping 
of  symptoms.  A  large  number  of  observers  have  added  to  the 
subject  since. 

Little  is  known  as  to  its  causation.     The  disease  affects  men 
oftener  than  women. 

Symptoms.  There  is  great  diversity  in  the  way  in  which  the 
symptoms  begin  :  Weakness  in  the  hands  or  arms.  A  sensa- 
tion of  numbness  may  be  felt.  Muscular  atrophy  is  added  to 
the  weakness  ;  it  is  of  the  type  of  progressive  muscular  atrophy 
(see  that  Disease) ;  it  may  begin  in  one  hand  or  both.  There 
are  loss  of  sensibiUty  to  pain  and  thermo-anse^hesia  ;  the  per- 
son is  unable  to  detect  the  difference  between  heat  and  cold  on 
a  more  or  less  extensive  area  of  the  body  ;  sometimes  the  per- 
son is  not  aware  of  this,  and  only  an  examination  reveals  it. 
Occasionally  the  patient  finds  that  he  has  burns  and  injuries, 
and  does  not  know  when  he  received  them— as  in  a  case  of  Starr's 
and  in  one  of  my  own.  Tactile  sensibility  and  the  muscular  sense 
are  unimpaired.  Sometimes  the  patient  complains  of  pains, 
tinglings  about  the  extremities,  joints,  and  back,  with  headache. 
The  reflexes  may  be  either  abolished  or  exaggerated.  Scoliosis 
is  spoken  of  as  almost  a  constant  symptom,  and  it  is  seated,  ac- 
cording to  Blocq,  in  the  dorso-lumbar  region  with  the  convexity  to 
the  right.  Trophic  disorders  are  quite  common.  The  muscular 
atrophy  usually  shows  first  in  the  hands  and  extends  afterwards 
to  other  parts ;  it  may  begin  in  the  shoulder  muscles  or  in  the 
lower  extremities.  Westphal,  Shultze,  and  Grasset  have  each 
observed  a  case  with  facial  paralysis.  There  may  be  fibrillary 
twitchings  in  the  mucles.  Electrical  excitability  is  usually 
diminished.  The  skin  is  often  affected  with  herpetic  and 
eczematous   eruptions,   and    the    atrophy   of   the    skin  called 


DEGENERATIVE    DISEASES    OF    SPINAL    CORD.       G9 


"glossy  skin"  has  been  described.  It  is  said 
the  nails  may  become  cracked,  furrowed,  and 
thick  ;  there  may  be  an  cedematous  condition 
of  the  cellular  tissue.  The  parts  may  be  cold 
andcyanosed  from  defective  circulation  ;  sliglit 
irritation  may  cause  persistent  redness  ;  the 
fingers  may  be  swollen  and  red.  The  joints 
are  sometimes  the  seat  of  arthropathies.  The 
bones  are  thickened  and  often  become  brittle. 
(Dejerine.) 

Diagnosis.  Muscular  atrophy,  thermo-anses- 
thesia  with  preservation  of  tactile  sensibility. 

Pathological  Anatomy.  Cavities  more  or 
less  large,  situated  generally  in  the  posterior 
portions  of  the  cord,  but  often  encroaching 
upon  the  other  parts  ;  they  are  usually  of  ir- 
regular shape  and  may  extend  throughout  the 
entire  cord  ;  these  cavities  are  the  result  of  a 
pathological  change  in  the  cord.  There  is  a 
development  ofa  glioma  or  gliosarcoma,  either 

Fig.  15. 


Fig.  14. 


Cavity  in  the  gray  matter.    Syringo  myelia.  (Personal  case.) 

starting  in  the  epithelial  lining  of  the  central 
canal  or  in  the  gray  substance  of  the  posterior 
horn  or  the  gelatinous  substance  ;  the  tumor 
develops  in  the  posterior  part  of  the  cord  and 
gradually  increases  ;  later,  the  central  portion 
of  the  tumor  breaks  down  and  a  cavity  is 
formed  ;  this  may  break  into  the  central  canal 

Fig.  14. — Showing  the  location  and  extent  of  the  gliomatous 
tumor  of  the  cord  and  cavity.    (After  Ira  Van  Gieson.) 


■lull 


70  NERVOUS    DISEASES    AND    INSANITY. 

if  it  did  not  start  originally  there  ;  all  below  the  tumor  the  central 
canal  is  dilated  by  cedematous  distention.  The  cavity  is  lined 
b}"  a  tissue  somewhat  loosel}^  arranged,  with  numerous  spider 
cells  and  glia  cells.  There  are  in  the  tumor  itself  the  glia,  or, 
as  in  Van  Gieson's  case,  gliosarcoma  cells. 

Bibliography.— West]^ha\^  Brain,  1883. — Eoth,  Archiv  de 
Neurologic,  1889.— Starr,  American  Journal  Medical  Sciences, 
1888. — Van  Gieson,  Journal  Nervous  and  Mental  Disease, 
1889.— J.  C.  Shaw,  New  York  Medical  Journal,  1890.— Com- 
plete bibliography  will  be  found  in  Starr  and  Roth's  papers. — 
Blocq,  Brain,  1890. 


Tetanoid  Paraplegia. 

(Spastic  Spinal  Paralysis ;  Spastic  Paraplegia ;  Tabes  Dcr- 
salis  Spasmodique ;  Primary  Sclerosis  of  the  Lateral 
Columns.) 

This  condition  was  first  described  by  Dr.  E.  C.  Seguin  in 
1873,  in  1875  by  Erb,  and  in  1876  by  Charcot. 

Etiology.  Heredity  is  said  to  play  a  part  in  its  causation  ; 
it  is  very  probably  secondary  to  other  pathological  conditions. 

Symptoms.  It  begins  as  a  weakness  in  the  lower  extremi- 
ties ;  the  legs  tire  easily,  and  if  long  walks  are  attempted, 
they  tremble,  give  way,  and  feel  heavy ;  the  feet  are  not  lifted 
from  the  ground  as  they  are  normally  in  walking,  but  shuffled 
along,  and  in  the  advanced  condition  they  scrape  along  the  floor  ; 
the  knees  are  slightly  bent ;  the  legs  present  a  rigid  appear- 
ance ;  in  motion  they  have  lost  the  suppleness  and  flexibility  at 
the  joints  observed  in  health  ;  when  the  person  sits  down  and 
arises  again  it  is  found  that  the  muscles  are  very  stiff",  and  it  is 
with  some  difficulty  that  he  arises  ;  it  is  soon  observed  that 
the  legs  tremble,  especially  if  the  muscles  are  put  on  the  stretch, 
as  in  an}-  awkward  position  which  the  legs  may  be  placed  in. 
There  may  be  spasm  in  the  legs,  especially  at  night ;  there  may 
be  some  aching  in  the  spinal  column.  If  the  legs  are  examined, 
they  are  found  to  be  more  or  less  rigid  and  resisting,  owing  to 


DEGENERATIVE    DISEASES    OF    SPINAL    CORD.       71 

muscular  contraction  ;the  muscular  power  is  good,  only  a  slight 
weakness.  The  reflexes  are  very  much  exaggerated,  and  the 
so-called  foot  phenomenon  or  ankle  clonus  is  marked.  This  is 
elicited  by  having  the  person  press  the  tip  of  the  toe  against 
the  rung  of  a  chair,  pressing  hard  against  it,  or  by  taking 
the  foot  in  your  own  hand,  and  flexing  it  forcibly  and  quickly 
against  the  leg,  at  the  same  time  making  slight  pressure  above 
the  knee  to  keep  the  leg  steady.  There  are  no  sensory  symp- 
toms ;  no  vesical  or  rectal  disorders  ;  no  muscular  atrophy  ;  no 
trophic  disorders.  The  disease  progresses  very  slowly  ;  it  is 
often  confined  entirely  to  the  lower  extremities,  but  ma}'^  involve 
the  upper  as  well.  Some  cases  of  spastic  paraplegia  have  been 
described  in  children  ;  but  I  believe  these  cases  are  due  to  some 
cerebral  disease  of  which  descending  degeneration  is  the  result, 
and  should  be  kept  apart  from  the  condition  here  described. 

Pathological  Anatomy.  A  primary  sclerosis  of  the  lateral 
columns,  if  such  a  condition  exists  without  lesion  in  other  por- 
tions of  the  central  nervous  system,  which  I  very  much  doubt. 
"We  have  very  little  knowledge  of  primary  lateral  sclerosis  ;  in 
combination  with  lesions  in  other  portions  of  the  spinal  cord  more 
is  known  (see  Combined  Sclerosis,  Friedreich's  Disease,  Lateral 
Amyotrophic  Sclerosis,  etc.).  The  location  of  this  lesion  will 
be  found  pictured  in  the  cut  of  the  spinal  cord  under  Lateral 
Amyotrophic  Sclerosis.     The  histological  changes  are  the  same. 

Diagnosis.  The  exaggerated  reflexes  :  the  muscular  spasm, 
and  the  consequent  spastic  walk ;  the  gradual  onset  of  the 
symptoms,  and  their  slow  progress  ;  the  absence  of  symptoms 
indicating  a  localized  transverse  lesion  ;  the  absence  of  sensory 
symptoms,  of  bladder  and  rectal  disorders  and  trophic  disturb- 
ances, and  the  appearance  of  the  disease  l^etween  30  and  50 
years  of  age. 

Prognosis.  Unfavorable  as  to  ultimate  recovery  ;  those  suifer- 
ing  from  it  may  live  a  great  many  years,  and  it  may  be  confined 
entirely  to  the  legs. 

Treatment.  Medication  is  useless,  unless  the  general  health 
is  impaired.  Massage,  cold  sponging,  electrical  treatment  of  a 
mild  kind. 


72  NERVOUS    DISEASES    AND    INSANITY. 


Locomotor  Ataxia. 

Etiology.  It  is  most  common  between  thirty  and  fifty  years 
of  age ;  it  affects  males  oftener  than  females  ;  a  neuropathic 
constitution  is  the  predisposing  cause  in  all  these  cases.  As 
exciting  causes  we  have  cold,  damp,  hardships  of  all  kinds. 
It  may  follow  some  of  the  acute  diseases  ;  falls  and  injuries 
are  said  to  act  as  exciting  causes.  Syphilis  is  a  frequent 
cause  ;  75  per  cent.  (Erb,  Seguin)  of  the  cases  have  a  syphilitic 
history  ;  the  syphihtic  poison  causes  disturbances  of  nutrition, 
which  lead  to  the  degenerative  changes  found  in  these  cases. 

Symptoms,  Lancinating,  lightning-like  pains,  or  boring  in 
character,  are  very  early  symptoms,  and  are  frequently  mis- 
taken for  rheumatism,  which  they  do  not  resemble  in  any  way  ; 
they  do  not  follow  the  course  of  any  nerve-trunk,  but  shoot 
about  in  the  various  cutaneous  branches.  The  lower  extremi- 
ties are  generally  first  aftected.  These  pains  come  on  with  great 
severity,  in  paroxysms,  lasting  a  few  hours  or  a  few  days  and 
subsiding.  They  may  precede  the  other  symptoms  for  years. 
There  is  numbness  in  the  feet  and  hands,  and  in  places  about 
the  legs  ;  the  feet  feel  thick  and  heavy,  and  the  patient  may 
be  unable  to  recognize  the  quality  of  the  substances  he  walks 
on.  Sensibility  is  retarded.  The  patella  tendon  reflex  is  lost ; 
tlie  pupils  are  contracted,  usually  alike,  but  one  may  be  larger 
than  the  other  ;  there  is  loss  of  reaction  to  light  and  preserva- 
tion of  reaction  to  accommodation  (Argylle  Robertson,  pupil). 
Diplopia  or  double  vision  ma)^  occur,  owing  to  paralysis  of  a 
muscle  of  one  eye  ;  it  often  comes  on  very  suddenly,  lasts  a 
variable  time,  and  may  pass  away  to  recur  again.  I  have  seen 
it  occur  and  pass  away  again  four  separate  times  in  one  case. 
The  ophthalmoscope  may  show  atrophy  of  the  optic  nerves. 
Slowness  in  micturition  occurs  very  frequently  ;  sometimes  there 
is  slight  dribbling  of  the  urine. 

Ataxia.  Persons  find  it  difficult  to  stand  or  walk  in  the 
dark  ;  they  sway  and  stagger  about,  and  this  difficulty  is  in- 
creased if  they  cannot  see  where  they  are  to  put  the  feet ;  or 
if  they  have  to  walk  on  a  narrow  space  or  through  a  narrow 


DEGENERATIVE    DISEASES    OF    SPINAL    CORD.       78 

Fig.  16. 


Showing  the  muscular  atrophy  contractures  and  deformities  in  a  case  of  loco- 
motor ataxia.    (Drawn  from  a  photograph  by  Dr.  Duryea.) 


74  NERVOUS    DISEASES    AND    INSANITY. 

doorway,  or  turn  about  quickly.  This  uncertainty  is  very  much 
increased  by  making  them  walk  with  the  eyes  shut.  If  they 
stand  with  the  eyes  shut,  they  reel  about  from  side  to  side,  and 
are  in  danger  of  falling  (Romberg,  symptom).  They  are  un- 
able to  touch  accurately  and  directly  objects  with  the  feet  or 
hands,  if  all  extremities  are  involved  in  the  disease  ;  especially 
if  the  eyes  are  shut.  Attacks  of  vomiting,  "gastric  crises," 
may  occur,  coming  on  suddenly,  lasting  a  few  hours,  or  a  few 
days,  and  ceasing  suddenly.  There  may  also  be  nephritic  crises 
.simulating  very  closely  nephritic  colic  ;  intense  pain  in  the  re- 
gion of  the  kidney,  with  bloody  urine  ;  it  ceases  suddenly.  They 
may  also  suffer  what  have  been  called  "  intestinal  crises  ;"  sud- 
den attacks  of  looseness  of  the  bowels  ;  a  kind  of  serous  diar- 
rhoea, which  also  ceases  suddenly.  Laryngeal  crises  are  also 
observed  ;  sudden  coughing  seizures,  with  great  difficulty  in 
breathing ;  the  face  distressed  and  turgid  ;  and  the  person  ap- 
pears in  imminent  danger  of  dying  ;  it  suddenly  ceases.  The 
suddenness  of  onset  and  of  disappearance  characterizes  all  these 
"crises."  There  may  be  permanent  paralj^sis  in  one  or  more 
of  the  eye-muscles,  and  ptosis  (paralysis  of  the  levator  palpe- 
hrse,  so  that  the  lid  droops  over  the  eyeball)  may  occur  in  one  or 
both  eyes.  Paralysis  of  the  anterior  tibial  group  of  muscles  in 
one  leg  may  occur ;  may  be  passing  or  permanent.  Muscular 
atrophy  may  occur  in  association  with  this  disease,  and  it  is 
usual  in  the  lower  extremities,  but  may  also  involve  the  upper  ; 
it  may  become  extreme  and  give  rise  to  contractures  and  de- 
formities of  the  feet. 

Apoplectiform  seizures  may  occur  in  which  the  person  is 
dazed,  confused,  and  has  difficulty  in  speaking  ;  this  is  of  tem- 
porary duration  ;  it  may  be  associated  with  hemiparesis  (partial 
paralysis  of  one  side  of  the  body),  or  there  may  be  a  hemiparetic 
attack  without  the  apoplectiform  state.  These  hemiparetic 
attacks  last  a  few  hours  or  a  few  days,  and  pass  away  entirely. 
As  trophic  disorders,  we  may  have  arthropathic  disease  of  some 
of  the  large  joints  ;  it  becomes  swollen  without  much  redness  ; 
it  is  very  much  distended,  and  oedematous-looking.  There  is 
usually  very  little  or  no  pain,  as  this  subsides  ;  dislocation  may 
be  discovered.     Sometimes  the  joint  remains  permanently  dis- 


DEGENERATIVE    DISEASES    OF    SPINAL    CORD.       75 

tended,  but  the  eroded  and  absorbed  heads  of  the  bones  can  be 
felt,  as  in  the  subject  of  the  accompanying  illustration. 


Fig.  17. 


Showing  arthropatliie  of  the  knee-joint  in  a  case  of  locomotor  ataxia,  from  the 
wards  of  St.  Catharine's  Hospital.    (Drawn  from  a  photograph  hyDr.  Slee.) 

This  man  can  throw  his  leg  about  without  the  least  pain. 
These  bones  are  found  to  have  undergone  extensive  disease  and 
absorption  of  their  ends  ;  there  may  be  evidences  of  an  effort  at 
repair. 

The  hip,  knee,  ankle,  elbow,  and  shoulder  are  most  frequently 
affected.  Changes  may  take  place  in  the  long  bones,  so  that 
they  become  very  brittle,  and  spontaneous  fractures  may  occur. 
These  conditions  are  not  very  common.  What  has  been  called 
perforating  ulcer  of  the  foot  may  occur  ;  it  is  usually  in  the  great 
toe.     Black  and  blue  spots  may  occur  under  the  skin  or  nails  at 


76  NERVOUS    DISEASES    AND    INSANITY. 

the  seat  of  severe  lancinating  pains,  or  without ;  they  are  due  to 
small  hemorrhages. 

Deafness  is  observed  in  a  few  cases.  In  one  case  noticed  by 
me  there  was  complete  loss  of  nerve  conduction,  as  shown  by 
the  tuning-fork. 

In  a  comparatively  few  cases  mental  symptoms  occur  ;  the 
memory  becomes  enfeebled ;  all  the  mental  faculties  are  im- 
paired ;  dementia.  There  may  be  some  passing  grandiose  ideas, 
such  as  are  found  in  general  paralysis  of  the  insane,  but  they 
are  not  usual ;  some  passing  delusions  of  persecution  are  more 
common  ;  epileptiform  seizures  occur  at  this  stage,  and  persons 
are  liable  to  die  in  one  of  tliem.  The  duration  of  the  disease  is 
very  variable.  A  great  many  persons  will  live  ten  or  twelve  years 
with  it,  and  even  longer  ;  others,  and  these  are  the  exceptional 
cases,  die  in  two  or  three  years  from  convulsions  ;  a  rapid 
progress  of  the  disease  or  a  diffuse  myelitis  is  set  up,  running  a 
somewhat  rapid  course  ;  or  the  person  may  die  of  some  intercur- 
rent disease,  of  which  Bright's  disease  is  the  most  common. 

Pathology.  It  has  for  some  time  been  known  that  the  ana- 
tomical lesion  in  this  disease  is  in  the  posterior  part  of  the  cord. 
In  recent  years  careful  pathological  studies  by  Pierret,  West- 
phal,  Striimpell,  Lissauer,  Flechsig,  Kaymond,  and  others — 
and  the  embrj^ological  studies  of  Flechsig  and  Betcherew,  with 
the  aid  of  improved  technical  methods,  staining  agents,  etc. — 
have  added  much  to  our  information  of  the  pathological  pro- 
cesses and  their  distribution,  and  have  shown  that  the  clianges 
and  the  location  of  the  lesion  are  not  so  simple  as  were  heretofore 
believed.  In  an  examination  of  sections  from  the  spinal  cord 
in  an  advanced  stage  of  the  disease,  the  entire  posterior  columns 
in  the  fresh  state  will  be  found  to  present  a  grayish  look.  In 
hardened  and  mounted  sections  these  columns  may  be  found 
diseased  in  their  entirety  ;  but  a  study  of  a  series  of  cases,  the 
subjects  of  which  have  died  early  in  the  course  of  the  disease, 
has  shown  that  there  is  a  pretty  uniform  localization  of  the  be- 
ginning lesion  in  the  column  of  Burdach. 

Autopsies  made  at  various  periods  of  the  diseavse  have  shown 
that,  later,  other  parts  are  involved,  but  that  there  is  no  uniformity 
in  the  succession  of  the  parts  subsequently  diseased.    The  entire 


DEaENBRATIVE    DISEASES    OF    SPINAL    CORD.      77 

column  of  Burdach  becomes  diseased  ;  the  columns  of  Goll ;  the 
posterior  roots  and  nerves ;  the  zones  of  Lissauer ;  Clark's 
columns  may  be  found  diseased  in  some  cases ;  the  direct  cere- 
bellar tract.     The  cells  in  the  posterior  horns  may  be  atrophied, 

Fig.  18. 


Showing  the  location  of  the  beginning  lesion. 

and  occasionally  Gower's  column  is  found  degenerated.  Many 
of  these  changes  are,  of  course,  secondary,  notably  the  disease  in 
Goll's  columns,  the  cerebellar  tract,  and  Gower's  columns  ;  they 
are  of  the  nature  of  secondary  degenerations. 

Histologically,  the  changes  in  the  posterior  columns  which  have 
been  called  "Sclerosis"  are  really  of  the  nature  of  a  degenera- 
tive process  ;  they  are  characterized  by  a  gradual  disappearance 
of  the  nerve-tubes,  sometimes  evidences  of  irritation  in  the  ves- 
sels and  neuroglia,  but  no  active  process  as  a  rule.  There  is  a 
small  amount  of  granular  material  scattered  among  the  diseased 
tissue  ;  occasionally  large  numbers  of  amyloid  bodies.  In  ad- 
vanced cases  where  the  nerve-fibres  have  largely  disappeared, 
there  is  retraction  of  the  neuroglia  tissue,  and  the  posterior 
column  looks  smaller  and  flattened  ;  some  posterior  spinal  menin- 
gitis may  be  observed,  but  it  is  not  always  present.    The  posterior 


78 


NERVOUS    DISEASES    AND    INSANITY. 


Fig.  19.  roots  are  atrophied.     The  disease 

begins  in  the  dorsal  region  usually, 
and  there  may  be  atrophy  of  the 
cells  in  Clark's  columns,  and  to 
some  extent  of  those  in  the  posterior 
horns.  The  extent  and  exact  dis- 
tribution of  the  lesions  vary  very 
much  in  different  cases  after  the 
early  stages.  Changes  have  been 
found  in  the  peripheral  nerves. 
But  these  are  probably  only  present 
in  the  more  advanced  stages  of  the 
disease.  These  changes  consist  in 
breaking  up  of  the  myeline  into 
irregular  masses,  which  are  scat- 
tered about  the  sheath  of  Schwann  ; 
there  appears  to  be  a  tendency  for 
this  process  of  disintegration  in  the 
myeline  to  begin  in  the  neighbor- 
hood of  the  constriction  of  Ranvier. 
There  is  a  resistance  of  the  axis  cy- 
linder to  this  disease  process  for  a 
long  time  ;  it  can  be  found  sharply 
stained  by  carmine  in  the  sheath, 
with  very  little  myeline  left.  There 
is  no  increase  in  the  size  of  the 
nuclei  such  as  is  seen  after  degene- 
ration of  the  nerve  from  section. 
These  changes  in' the  nerve  are  most 
marked  at  its  terminal  ends,  but 
it  is  also  found  extensively  in  the 
trunks. 

Diagnosis.  Lancinating  pains, 
ataxia,  pupillary  changes  (described 
above),  absent  tendon  reflex,  are 
sufficient  to  make  the  diagnosis. 

Prognosis.    Unfavorable  as  to  recovery ;  it  is  slowly  pro- 
gressive. 

Treatment.    Iodide  of  potassa  in  some  cases  appears  to  improve 


Davis.  Well-marked  case  of 
Locomotor  Ataxia,  with  severe 
lancinating  pains.  Shaded  re- 
gion shows  diseased  area. 


DEGENERATIVE    DISEASES    OF    SPINAL    CORD.      79 

the  condition,  but  it  never  cures,  even  those  cases  which  have  a 
clear  syphiUtic  history.  As  internal  remedies,  perhaps  Dono- 
van's solution  is  as  good  as  any.  If  the  physicial  condition 
is  poor,  nutritious,  easily   digestible  food  with  cod-liver  oil. 

Fig.  20. 


Advanced  disease  of  the  posterior  column,  nerve-fibres  in  all  stages  of  degenera- 
tion.   There  are  very  few  fibres  left. 

For  the  relief  of  symptoms,  the  lancinating  pains  are  the  most 
troublesome.  Antifebrin  in  10-grain  doses  when  the  pains  begin 
will  often  give  relief  (phenacetin  and  antipyrine  are  not  nearly 
so  efficacious) ;  it  should  not  be  repeated  too  frequently.  There 
are  cases  in  which  this  dose  will  fail  to  give  relief;  in  fact,  an}'- 
dose  which  is  safe, — and  nothing  but  a  hypodermic  of  morphia 
will  allay  the  excruciating  pains.  Very  recently  suspension  with 
Sayre's  apparatus  (for  putting  on  the  plaster-jacket)  and  modi- 
fications have  been  used  ;  in  some  cases  it  gives  relief  to  many 
of  the  symptoms— among  them,  the  pain,  ataxia,  and  bladder 
S3''mptoms  ;  in  others  it  does  not  appear  to  be  at  all  beneficial. 
In  making  application  of  the  suspension  apparatus,  care  should 
be  taken  to  learn  if  there  are  contraindications  to  its  use  :  heart 
disease,  serious  disease  of  the  bloodvessels,  or  great  weakness 
are  the  chief  ones.  The  suspension  should  be  very  slowly  and 
cautious.  On  the  least  evidence  of  ill  effect,  the  person  should 
be  lowered.  It  should  not  be  continued  more  than  half  a  minute 
the  first  time,  and  gradually  increased  to  two  or  three  minutes 
if  it  is  borne  well ;  it  can  be  practised  every  other  day.  Bella- 
donna often  gives  relief  to  the  dribbling  and  involuntary  dis- 
charge of  urine.  Overwork  of  all  kinds,  sexual  and  alcoholic 
excesses  should  be  carefully  avoided.     Only  a  moderate  amount 


80  NERVOUS    DISEASES    AND    INSANITY. 

of  walking  should  be  done.  Cold.and  damp  should  be  avoided, 
A  residence, temporarily  at  least  in  a  dry  elevated  climate,  with 
freedom  from  work  and  worry,  often  gives  rise  to  improvement. 

Bibliography. — The  various  works  on  Nervous  Diseases. — 
E.  C.  Seguin,  American  Clinical  Lectures,  1878,  Opera  Minora, 
1884. — J.  C.  Shaw,  Transactions  Kings  County  Medical  Society, 
1879. — Buzzard,  Lectures  on  Diseases  of  the  Nervous  System, 
1882.— Hale  White,  Brain,  1886.— J.  C.  Shaw,  Apoplectiform, 
Epileptiform,  and  Hemiparetic  Attacks  in  Locomotor  Ataxia, 
N.  Y.  Med.  Journal,  1888.— J.  C.  Shaw,  Degeneration  of  the 
Peripheral  Nerves  in  Locomotor  Ataxia  ;  Journal  Nervous  and 
Mental  Dis.,  1888. 

The  literature  on  Locomotor  Ataxia  is  enormous.  Additional 
references  will  be  found  in  the  articles  referred  to  and  in  special 
journals. 

Friedreich's  Disease. 

(Hereditary  Ataxia;  Postero-Lateral  Spinal  Sclerosis  of 
Generic  Origin,  Dr.  Everett  Smith.) 

This  disease  was  first  discribed  by  Friedreich  in  1861.  It 
develops  in  children  at  any  early  age,  as  the  result  probably  of 
hereditary  influences,  and  it  usually  affects  several  children  in 
the  same  family  ;  but  isolated  cases  are  not  unfrequent.  It  occa- 
sionally develops  as  the  individual  grows  up.  There  may  be  a 
neurotic  family  history;  the  sexes  are  about  equally  affected. 

Symptoms.  It  is  first  shown  by  an  unsteadiness  in  walking  ; 
the  child  is  awkward,  falls  easily  and  frequently  ;  as  the  disease 
advances  the  upper  extremities  are  affected  ;  they  become  like 
the  legs  ;  the  person's  movements  are  disorderly. 

This  increases  ;  soon  difficulty  in  speech  is  observed  ;  it  is 
slow  and  hesitating,  and  can  become  quite  unintelligible, 
owing  to  the  disorderly  movement  of  the  muscles.  In  one  case 
which  I  have  observed  for  years  the  symptoms  began  at  11  years 
of  age  and  have  gradually  increased  until  the  difficulty  in  speech 
is  so  great  it  is  almost  impossible  to  understand  her ;  the  ataxic 
symptoms  have  become  so  great  she  cannot  walk  without  sup- 


DEGENERATIVE    DISEASES    OF    SPINAL    CORD.       81 

port,  and  the  motions  are  then  the  most  disorderly  possible,  in 
both  arms  and  legs,  for  in  attempting  to  walk  she  also  puts  the 
arms  in  motion.  She  is  now  over  40  years  old.  Nystagmus  is 
said  to  occur  in  some  of  these  cases.     The  tendon  reflex  is  lost 

Fig.  21. 


Showing  the  attitude  and  deformities  of  the  feet.    (Drawn  from  illustrations  by 

Dr.  W.  E.  Smith.) 

in  most  of  the  cases,  but  it  may  be  present  and  even  exaggerated 
in  some  cases.  Spinal  curvatures  may  be  present.  There  may 
be  pains,  but  they  are  not  lightning-like,  but  dull,  and  may  be 
severe,  located  in  one  spot  for  a  long  time  ;  as  a  rule,  sensibility 
is  normal,  but  there  may  be  slight  anaesthesia.  Contractures 
may  occur  in  the  lower  extremities.  There  are  no  pupillary 
changes. 

Diagnosis.  From  locomotor  ataxia,  Friedreich's  disease 
begins  usually  in  very  young  children  ;  only  rarely  the  first 
symptoms  appear  at  an  age  when  locomotor  ataxia  is  common  ; 
absence  of  lightning  pains,  of  marked  sensory  symptoms,  of 
bladder  disturbances,  of  diplopia,  and  "  crisis"  of  abdominal 
symptoms,  constriction  in  hypogastric  region,  of  arthropathies. 
The  very  slow  evolution  of  Friedreich's  disease. 


82 


NERVOUS    DISEASES    AND    INSANITY. 


From  disseminated  sclerosis  with  which  it  is  most  Ukely  to  be 
confounded.  There  is  no  tendency  in  disseminated  sclerosis  to 
occur  in  several  members  of  a  family  ;  the  disordered  movements 
are  more  jerky  and  slow,  the  disorder  of  speaking  is  different, 
more  slow  and  drawling,  hesitating  than  in  Friedreich's  disease, 
a  tendency  to  convulsions  in  disseminated  sclerosis,  and  the 
walk  is  spastic. 


:^^l^:^i-^^. 


Showing  the  changes  in  the  posterior  and  lateral  columns  (shaded  regions)  of 
the  spinal  cord.  (Drawn  from  illustrations  by  Dr.  W.  E.  Smith,  Boston  Medical 
and  Surgical  Journal,  1885.) 

Pathological  Anatomy.  It  has  been  found  that  the  spinal 
cord  is  smaller  than  the  normal  in  all  these  cases.  There  appears 
to  be  a  defect  in  its  development.  The  result  is  that  sooner  or 
later  it  undergoes  a  premature  pathological  process,  and  this 


DEGENERATIVE    DISEASES    OF    SPINAL    CORD.       ^3 

takes  place  in  the  posterior  and  lateral  columns.  The  extent 
to  which  these  colunins  have  been  found  diseased  varies  some- 
what, as  the  accompanying  illustrations  will  indicate. 

Fig.  23. 


-ys 


Section  of  the  spinal  cord  in  a  case  of  Friedreich's  disease,  posterior  and  lateral 
columns  diseased  (unshaded  portions  show  diseased  area).  Diseased  areas,  Gower's 
column  (?);  pyramidal  bundles;  direct  cerebellar  bundles;  columns  of  Burdach; 
columns  of  Goll ;  columns  of  Clark.  Band  of  healthy  tissue  around  the  posterior 
horn,  central  canal,  and  external  zones  of  Lissauer  healthy.  (Drawn  from  an  illus- 
tration by  Blocq  and  Marinesceo,  Archiv  de  Neurologic,  1890.) 

Histologically,  some  authors  have  described  posterior  spinal 
meningitis,  but  in  the  majority  of  these  cases  it  has  not  been 
found  ;  the  gray  degeneration  of  the  posterior  columns  has  been 
constant,  atrophy,  and  disappearance  of  the  nerve  fibres,  with 
some  thickening  of  the  neuroglia,  flattening  of  the  cord  from 
before  backward.  Degeneration  of  Clark's  columns  and  of  the 
cerebellar  tract  and  atrophy  of  the  posterior  roots  have  been 
found. 


Bibliography.— W.  A.  Hammond,  Journal  :N'ervous  and  Men- 
tal Disease,  1882.— Dr.  W.  Everett  Smith,  Boston  Medical  and 
Surgical  Journal,  1885.— E.  C.  Seguin,  K  Y.  Medical  Record, 
1885.— Sinkler,  Medical  IS^ews,  Phila.,  1885. -Morton  Prince, 
Boston  Medical  and  Surgical  Journal,  1885.  -  Judson  Bury, 
Brain,  1886.— C.  L.  Dana,  N.  Y.  Medical  Eecord,  1887.— 
Ormerod,  Brain,  1888.— J.  F.  C.  Griffith,  American  Journal 
Medical  Sciences,  1888.— W.  Everett  Smith,  Boston  Medical  and 
Surgical  Journal,  1888.— Ladam,  Brain,  1890. 


84 


NERVOUS    DISEASES    AND    INSANITY. 


Combined  Sclerosis. 

(Ataxic  Paraplegia.) 

Under  the  general  designation  of  combined  sclerosis  have 
been  classed  a  number  of  conditions  whose  sj^mptomatology  and 
even  pathological  anatomy  are  not  fully  made  out. 

Friedreich's  disease  and  ataxic  paraplegia  are  types  as  far  as 
the  pathological  anatomy  are  concerned. 


Ataxic  Paraplegia. 

Etiology.  Heredity,  syphilis,  excessive  physical  labor,  ex- 
posure, alcoholic  and  venereal  excesses  ;  it  occurs  also  in  elderly 
persons  who  have  been  subject  to  much  privation  and  anxiety. 

Symptoms.  It  begins  usually  very  slowly,  by  stiffness  and 
trembling  in  the  lower  extremities,  with  soreness  and  aching. 
Early  the  sexual  vigor  is  lost ;  there  is  gradually  developed 
marked  motor  weakness  ;  there  may  be  a  feeling  of  numbness 
in  the  legs  ;  and  occasionally  lightning-like  pains  are  present, 
but  they  are  not,  as  a  rule. 

Fig.  24. 


Ataxic  paraplegia.    Shaded  regions  indicate  the  disease  in  the  white  matter. 
(Drawn  from  an  illustration  by  Dr.  Qark,  Brain,  1890.) 

Ataxia  is  always  present,  as  shown  by  inco-ordinate  movements 
in  walking  or  standing  with  eyes  shut,  etc.  The  gait  is  a  mix- 
ture of  locomotor  ataxia  and  spastic  paralysis.  There  may  be 
dribbling  or  slowness  of  urination.  The  reflexes  are  exaggerated. 
The  symptoms  are  often  confined  to  the  lower  extremities,  but 


MUSCULAR    DYSTROPHIES.  85 

the  upper  may  be  affected.  As  complications  there  may  be 
mental  disease  somewhat  similar  to  that  observed  in  locomotor 
ataxia. 

Pathological  Anatomy.  The  lesion  is  a  sclerosis  of  the  lateral 
and  posterior  columns  somewhat  similar  in  distribution  and 
histologic  changes  to  that  found  in  Friedreich's  disease.  The 
accompanying  illustrations  will  show  the  distribution  of  the 
lesion. 

Diagnosis.  The  slow  progress  of  the  disease,  the  association 
of  ataxia,  paresis,  exaggerated  reflexes. 

Prognosis.  It  is  a  slowly  progressive  disease  ;  there  is  slight 
tendency  for  it  to  cause  death. 

Treatment.  Must  be  the  same  as  recommended  in  locomotor 
ataxia,  Friedreich's  disease,  etc. 

Bibliography.— Ormerod,  Brain,  1885.— Dana,  Xew  York 
Medical  Record,  1886,  and  Brain,  1889.  — J.  J.  Putnam,  Journal 
Nervous  and  Mental  Disease,  1891.— J.  Mitchell  Clark,  Brain, 
1890.— Grasset,  Archiv  de  Neurol.,  1886. 


CHAPTER  III. 
Muscular  Dystrophies. 

This  is  the  name  given  to  a  class  of  muscular  atrophies  which 
are  quite  evidently  not  of  nervous  origin,  but  are  in  the  muscles 
themselves.  Pseudo-hypertrophic  muscular  atrophy,  the  oldest 
known  of  this  group,  has  always  been  considered  among  diseases 
of  the  nervous  system,  probably  because  of  its  resemblance  to 
the  group  of  myelopathic  muscular  atrophies  and  the  suspicion 
that  it  also  was  due  to  some  nerve  changes. 

Pseudo-Hypertrophic  Paralysis. 

(Muscular  Pseudo-Hypertrophy.) 

Etiology.  Males  are  oftenest  affected  ;  it  occurs  very  often  in 
several  members  of  a  family,  but  individual  cases  are  also  met 


86  NERVOUS    DISEASES    AND    INSANITY. 

with.  In  many  cases  there  is  no  history  of  the  ancestors  having 
been  affected.  In  other  instances  there  is  an  hereditary  trans- 
mission, and  it  is  always  througli  the  mother,  but  who  is  not  the 
subject  of  the  disease  herself.  It  has  been  observed  that  the 
children  of  a  woman  by  different  husbands  have  been  affected. 
It  always  begins  very  early  in  life  ;  it  may  be  first  observed  when 
the  child  begins  to  walk. 

Symptoms.  Impairment  of  muscular  power  as  shown  by 
difficulty  and  awkwardness  in  motion,  often  falls  ;  finds  dif- 
ficulty in  going  up  a  stairs,  takes  hold  of  the  banister  to  pull 
itself  up  by;  the  muscles  may  present  nothing  unusual ;  later 
an  enlargement  of  some  of  the  muscles  may  be  observed, 
and  this  is  most  frequently  in  the  calf  muscles  ;  this  may  be 
made  more  apparent  by  atrophy  of  the  thigh  muscles.  The 
extensors  of  the  knee,  the  gluteal  and  lumbar  muscles  are 
often  enlarged,  and  the  infra  spinatus  (Gowers).  The  lower 
border  of  the  pectoralis  and  latissimus  dorsi  are  often  wasted  ; 
the  muscles  of  the  forearm  are  only  affected  in  a  small  propor- 
tion of  the  cases.  The  weakened  muscles  cause  difficulties  and 
peculiarities  in  movement,  the  walk  is  swaying  from  side  to  side, 
there  is  marked  lordosis  in  some  cases,  there  is  marked  diffi- 
culty in  raising  from  the  floor  or  from  a  seat  or  going  up  a  step 
where  there  is  no  rail  to  hold  on  to  ;  one  hand  is  placed  on  the 
knee  and  the  body  is  pushed  up.  The  shortening  and  con- 
tracture which  may  occur  in  some  of  the  muscles  give  rise  to 
abnormal  positions  of  the  body  and  extremities ;  there  may  be 
contracture  of  the  calf  muscles  so  that  the  heel  cannot  be 
brought  to  the  ground.  A  few  years  ago  I  was  consulted  by  a 
young  lady,  aged  22,  because  of  an  inability  to  put  the  heel  of 
one  foot  to  the  ground.  She  had  no  other  symptoms  and  pre- 
sented every  appearance  of  being  in  good  health  ;  examination 
showed  that  the  calf  muscles  on  that  leg  were  double  the  size  of 
the  other.  She  said  this  enlargement  had  existed  as  long  as  she 
could  remember,  and  she  had  only  in  the  past  six  months  expe- 
rienced this  difficulty  in  putting  the  heel  on  the  ground  ;  there 
was  no  hypertrophy  or  atrophy  any  where  else  ;  she  could  go  up 
and  down  stairs  without  any  difficulty.  Curvature  of  the  spine 
may  occur  as  the  result  of  muscular  weakness.     There  may  be 


MUSCULAR    DYSTROPHIES. 


87 


diminution  of  electrical  reaction,  but  no  degenerative  reaction. 
The  tendon  reflex  is  at  first  normal,  but  an  the  extensors  of  the 
knee  atrophy  it  is  lost. 

Fig.  25. 


Showing  the  muscular  wasting  in  the  gluteal  and  thigh  muscles ;  hypertrophy 
(pseudo)  of  the  calf  muscles ;  contracture  in  gastrocnemius  on  one  side,  so  that 
the  heel  cannot  be  brought  to  the  floor,  not  well  shown  in  the  photograph.  Lordosis. 
(Drawn  from  a  photograph  by  Dr.  Slee ) 


Pathological  Anatomy.  Atrophy  of  the  muscles,  absence  and 
wasting  of  the  fibres,  the  presence  of  large  quantities  of  fat  and 
connective  tissue,  the  motor  nerves  have  not  been  found  diseased, 
and  the  spinal  cord  is  normal.  It  is  evidently  a  congenital  de- 
fect in  the  construction  and  vitality  of  the  muscle,  so  that  it 
prematurely  undergoes  atrophic  changes. 

Diagnosis.     The  age,  the  muscular  hypertrophy  in  certain 


88  NERVOUS    DISEASES    AND    INSANITY. 

muscles,  and  atrophy  in  others  ;  the  pecuHar  gait  and  mode  of 
rising,  etc. 

Prognosis.  Not  favorable  ;  if  the  disease  develops  late,  it  is 
possible  it  may  progress  very  slowly. 

Treatment.  No  treatment  has  been  found  beneficial.  Gowers 
believes  that  muscular  exercise  has  some  influence  in  retarding 
the  progress  of  the  disease  ;  massage  and  electricity  may  be  of 
some  service  ;  if  contractures  occur,  tenotomy  may  be  resorted 
to  for  the  rehef  of  the  deformities. 

In  tlie  last  decade  there  has  been  much  activity  in  describing 
and  dividing  up  into  types,  with  special  names,  some  of  these 
muscular  dystrophies.  Tliese  divisions  are  evidently  artificial, 
in  spite  of  their  apparent  individuality,  and  aramost  probably 
variations  in  the  group  of  muscles  first  attacked,  in  its  mode  of 
progress,  etc. 

Eib's  Juvenile  Atrophy.  In  1884  (second  article)  Erb  de- 
scribed a  muscular  wasting,  which  has  since  been  known  under 
the  above  designation.  It  occurs  in  children  or  youth  as  a 
weakness  and  atrophy  of  the  muscles  of  the  shoulder,  upper 
arm,  and  pectoral  region,  thigh  and  back  ;  the  forearm  and  leg 
muscles  are  said  not  to  be  affected  for  a  long  time.  The  atrophy 
may  be  associated  with  true  or  pseudo-hypertrophy  of  some 
muscles,  ribrillary  contractions  and  reaction  of  degeneration 
are  said  never  to  be  present.  There  are  no  sensory  or  vesical 
disorders.  The  wasting  is  in  the  pectorals,  trapezius,  latissimus 
dorsi,  serratus,  and  rhomboids,  as  well  as  most  of  the  upper  arm 
muscles,  while  the  deltoids,  supra-  and  infra-spinatus  are  either 
hypertrophied  or  normal  for  a  long  time. 

More  recently  a  variety  has  been  described  by  Landouzy  and 
Dejerine — the  Landouz3'-T)ejerine  or  fascio-scapulo-humeral 
type.  It  begins,  as  a  rule,  in  early  life,  and  in  the  muscles  of 
the  face,  and  gives  rise  to  a  characteristic  thickening  of  the  lips, 
which  they  have  described  as  tapir  mouth  ;  later  the  atrophy 
affects  the  muscles  of  the  shoulder  and  arms,  supra-  and  infra- 
spinatus, subscapularis  ;  flexors  of  the  hand  and  fingers  remain 
normal ;  exceptionall}^  it  may  begin  in  the  muscles  of  the  shoul- 
der and  arm,  or  even  in  the  lower  extremities.     It  is  distinctly 


MUSCULAR    DYSTROPIITES.  89 

hereditary  ;  fibrillary  contracLion  and  reaction  of  degeneration 
are  never  present. 

A  variety  has  been  described  by  Leyden  as  hereditary  pro- 
gressive muscular  atrophy. 

Heredity  is  the  prominent  cause  in  all  these  cases.  It  begins 
gradually  as  a  weakness  and  wasting  in  muscles  or  muscular 
groups  at  an  early  period  of  life.  The  tongue,  muscles  of  mas- 
tication, and  pharynx  are  never  affected.  The  electrical  irrita- 
bility may  be  diminished,  but  there  is  no  reaction  of  degeneration. 
Some  shortening  of  the  muscles  has  been  observed,  especially 
the  calf  muscles  ;  deformities  may  occur  as  in  progressive  mus- 
cular atrophy.  Its  course  and  duration  are  variable  ;  it  may 
remain  confined  to  one  part  or  extend  to  others. 

Bibliography.  — T>.  Sachs,  New  York  Medical  Journal,  1888, 
where  a  full  list  of  references  will  be  found. 


Acromegaly. 

In  1886  Pierre  Marie  first  gave  a  description  of  this  disease 
from  a  study  of  two  cases  in  the  wards  of  Prof.  Chan^ot.  Since 
then  contributions  have  been  made  to  the  subject  by  Marie  and 
others.  A  summarized  account  of  the  condition  only  will  be 
given  here  from  Marie's  articles. 

It  is  characterized  by  a  truly  remarkable  hypertrophy  of 
the  extremities,  hands,  feet,  and  head.  The  hands  are  enor- 
mous, their  form  is  regular,  but  width  out  of  proportion  to  their 
length  ;  the  fingers  present  a  "  sausage-shaped"  form  ;  there  is 
often  swelling  of  the  articulations  of  the  first  and  second  i)ha- 
langes,  with  a  certain  flattening  of  the  fingers  in  the  antero- 
posterior direction.  The  palmar  lines  are  exceedingly  marked 
and  bordered  by  enormous  folds.  The  hypertrophy  affects  not 
only  the  skeleton,  but  to  a  marked  degree  the  soft  parts  ;  it  is 
especially  developed  at  the  upper  part  of  the  hand  and  its  ulnar 
border.  The  nails  are  flattened,  rather  widened,  and  their  lateral 
borders  are  sometimes  curved  up.  The  feet  are  enormous  ;  on 
their  external  border  the  mass  of  tissue  forms  an  enormous  pad. 


90 


NERVOUS    DISEASES    AND    INSANITY. 


The  malleoli  are  generally  increased  in  size  ;  to  a  less  degree  the 
head  of  the  fibula  and  the  upper  extremity  of  the  tibia  ;  otlier- 

wise  the  size  of  the  legs  is  not 
much    increased.      The    knees 


Fig.  26. 


Acromegaly.     (Drawn  from  an  illus- 
tration by  Marie.) 


often  appear  prominent,  owing 
to  increase  in  size  of  the  patella 
and  condyles  of  the  femur.  Di- 
ameter of  the  thigh  unchanged. 
The  cephalic  extremity  is  in- 
creased in  size  ;  especially 
marked  in  the  prominent  parts 
of  the  face.  The  cranium  is  but 
little  altered  in  shape  and  size; 
the  face  appears  elongated  ver- 
tically ;  forehead  usually  rather 
low,  with  marked  prominence 
of  orbital  arches  (due  especially 
to  dilatation  of  the  frontal  sin- 
uses). The  eyelids  are  often 
elongated  ;  thickened  ;  their  tar- 
sal cartilages  may  be  hypertro- 
phied.  The  nose  is  increased 
in  all  its  dimensions,  it  is  enor- 
mous ;  the  cheeks  generally  flat- 
tened and  elongated  ;  the  cheek 
bones  prominent  and  bulky. 
The  increase  in  the  size  of  the 
lower  lip  contributes  greatly  to 
give  the  patient  the  remarkable 
physiognomy  which  makes  him 
recognizable  at  a  distance  and 
at  a  glance.  The  lip  is  promi- 
nent and  strongly  everted.  The 
upper  lip  may  be  a  little  thick- 
ened, but  not  comparable  to  the 
lower.  The  chin  projects  mark- 
edly downwards  and  forwards, 
it  is  large  and  massive;  the  lower 


MUSCULAR    DYSTROPHIES.  91 

jaw  is  increased  in  size,  and  as  the  upper  jaw  does  not  undergo 
the  same  modifications  a  very  marked  degree  of  prognathi.-m 
often  ensues.  The  tongue  is  of  enormous  dimensions,  and  in 
some  cases  double  its  normal  size  ;  its  shape  remains  perfectly 

Fig.  27. 


Showing  the  shape  and  size  of  the  hands  in  Acromegaly.     (Drawn  from  an 
illustration  by  Marie.) 

regular  ;  its  increase  is  in  all  directions.  These  modifications 
of  the  tongue  and  lips  sometimes  interfere  with  articulation. 
The  ears  are  sometimes  increased  in  size.  There  is  a  marked 
kyphosis  in  the  upper  part  of  the  dorsal  region  ;  the  patient's 
head  is  buried  in  his  shoulders  in  consequence.  The  vertehrte 
are  very  much  hypertrophied.  The  neck  is  short  and  thick. 
There  is  an  enormous  increase  in  the  thorax.  Headache  is  pre- 
sent, and  pains  in  joints  in  a  certain  number  of  cases.  There 
are  no  mental  disturbances. 

Bibliography. — Marie,  Rev.  de  Medecine,  1886  ;  Le  Progres 
Medical,  1889;  Brain,  1889.— Adler,  Medicinische  Monatschrift, 
N.  Y.,  1890.— Eoss,  International  Chnics,  1891. 

Localization  of  Lesions  in  the  Spinal  Cord. 

Only  a  few  words  can  be  said  here  on  this  subject.  The  stu- 
dent must  refer  to  the  works  on  physiology,  and  with  the  aid  of 
the  accompanying  table  from  Starr  and  the  diagram  of  the 
spinal  segments  and  their  nerves,  in  relation  to  the  vertebra, 
he  will  have  ample  material  for  study  and  locating  lesions  in 
the  cord.     This  study  is  of  importance,  as  in  injuries  of  the 


92 


NERVOUS    DISEASES    AND    INSANITY. 


Fig.  28. 


--f 


-ID 


cord  by  fracture,  tumor,  etc.,  the 
possibility  of  surgical  interference 
as  a  means  of  relief  must  be  con- 
sidered :  and  it  is  necessary  to  locate 
the  lesion. 

Lesions  of  the  cauda  equina  give 
rise  to  paralysis,  anaesthesia,  atrophy 
of  muscles,  and  reaction  of  degenera- 
tion in  the  distribution  of  the  sciatic 
nerve  ;  the  sphincter  ani  is  para- 
lyzed, while  the  bladder  may  remain 
normal.  Lesions  of  the  lower  lum- 
bar enlargement  give  rise  to  the 
same  symptoms. 

Lesions  of  the  upper  and  mid- 
lumbar  cord  cause  paraplegia  with- 
out paralysis  of  the  abdominal  mus- 
cles. The  paralyzed  muscles  retain 
their  normal  electrical  reactions, 
and  the  reflexes  are  increased. 
The  sphincter  is  usually  paralyzed. 
Lesions  of  the  dorsal  cord  cause 
paralysis  and  anaesthesia  of  all  parts 
below  the  lesion.  The  line  of  anaes- 
thesia indicates  the  seat  of  lesion  ; 
the  sphincters  are  paralyzed  and 
reflexes  exaggerated. 

Lesions  at  last  cervical  and  first 
dorsal ;  paralj^sis  in  the  ulnar  dis- 
tribution and  anaesthesia  of  the 
lower  forearm,  ulnar  side  of  hand 
and  fingers  ;  paralysis  of  flexor  carpi 
ulnaris,  etc.  Paralysis  of  intercostal 
muscles  ;  the  line  of  body  anaesthe- 
sia just  below  clavicle. 

A  reference  to  the  table  and  dia- 
gram will  make  this  plain.     Para- 


Spinal  cord.    (After  Gowers.) 


SPINAL    LOCALIZATION. 


98 


lysis  may  be  caused  by  a  lesion  in  the  anterior  horn  of  the 
spinal  cord  ;  the  muscles  atrophy,  and  their  electrical  reactions 
are  changed,  and  the  reflexes  are  lost,  for  those  muscles  inner- 
vated by  that  diseased  spinal  segment.  If  the  paralysis  is 
due  to  an  interference  with  the  transmission  of  voluntary  motor 
impulses,  through  the  pyramidal  tract,  as  in  paral3'sis  from 
brain  disease,  the  muscles  do  not  atrophy  ;  the  reflexes  are 
exaggerated ;  the  tonicity  of  the  muscles  is  increased,  and 
there  may  be  rigidity  ;  the  normal  electrical  reactions  arc  pre- 
served.    Loss  of  reflex  indicates  a  lesion  which  interferes  some- 


FiG.  29. 


1.  Column  of  Goll.  2.  Column  of  Burdaeh.  3.  Internal  marginal  zone  of  Lis- 
sauer.  4.  External  marginal  zone  of  Lissauer.  5.  Crossed  pyramidal  tract.  6. 
Direct  pyramidal  tract.  7.  Direct  cerebellar  tract.  8.  Gowers'  tract.  9.  Deep 
portion  of  lateral  column. 

where  with  the  reflex  arc  for  that  spinal  segment,  formal 
reflex  indicates  that  the  arc  is  intact  ;  exaggerated  reflex  that 
the  inhibitory  action  of  the  brain  is  removed,  and  always  indi- 
cates a  cutting  off*  (or  irritation)  of  the  pyramidal  tract  from  the 
brain  somewhere  in  its  course  ;  the  reflex  is  exaggerated  below 
the  focus  of  disease. 


9i 


NERVOUS    DISEASES    AND    INSANITY. 


Localization  of  the  functions  of  the  segments  of  the 
spinal  cord.    {Starr.) 


Segment. 


2(1  and  3d 
cervical 


4tli 
cervical 


5th 
cervical 


Muscles. 


EeFIiEX. 


6th 
cervical 


7th 
cervical 


8th 
cervical 


1st 
dorsal 


2d  to  12th 
dorsal 


Sterno-mastoid,  trape- 
zius, scaleni  and  neck, 
diaphragm. 


Diaphragm,    deltoid, 
biceps,  coraco-brachi- 
alis,  supinator  longus, 
rhomboid,  supra-  and 
infra-spinatus. 

Deltoid,  biceps,  coraco- 
braehialis,  brachialis 
anticus,  supinator  lon- 
gus, supinator  brevis, 
rhomboid, teres  minor, 
peetoralis,  serratus 
magnus. 


Biceps,  brachialis  anti- 
cus, peetoralis   (clavi- 
cular part),  serratus 
magnus,  triceps,  ex- 
tensors of  wrist  and 
fingers,  pronators. 


Triceps  (long  head),  ex- 
tensors of  wrist  and 
fingers,  pronators  of 
wrist,  flexors  of  wrist, 
subscapular,  peetora- 
lis (costal  part),  latis- 
simus  dorsi,  teres 
major. 

Flexors  of  wrist  and 
fingers,  intrinsic  mus- 
cles of  hand. 

Extensors  of  thumb, 
intrinsic  hand  mus- 
cles, thenar  and  hypo- 
theuar  eminences. 

Muscles  of  back   and 
abdomen,  erectores 
spinse. 


Hypochondrium(?);  sud- 
den inspiration  produced 
by  sudden  pressure  be- 
neath the  lower  border 
of  ribs. 

Pupil,  4th  to  7th  cervical ; 
dilatation    of  the   pupil 
produced  by  irritation 
of  the  neck. 


Scapular,  5th  cervical  to 
1st  dorsal ;  irritation  of 
the  skin  over  scapula  pro- 
duces contraction  of  the 
scapula  muscles,  sujjina- 
tor  longus;  tapping  its 
tendon  in  wrist  produces 
flexion  of  forearm. 

Triceps,  5th  to  6th  cervi- 
cal ;  tapping  elbow  ten- 
don produces  extension 
of  forearm ;  posterior 
wrist,  6th  to  8th  cervical ; 
tapping  tendon  causes 
extension  of  hand. 

Anterior  wrist,  7th  to  8th 
cervical ;  tapping  ante- 
rior tendons  causes  flex- 
ion of  wrist ;  palmar,  7th 
cervical  to  first  dorsal ; 
striking  jDalra  causes  clo- 
sure of  fingers. 


Sensation. 


Epigastric,  4th  to  7th  dor- 
sal ;  tickling  mammary 
region  causes  retraction 
of  the  epigastrium ;  ab- 
dominal, 7th  to  11th  dor- 
sal; striking  side  of  ab- 
domen causes  retraction 
of  belly. 


Back  of  head  to  ver- 
tex; neck. 


Neck,  upper  shoul- 
der, outer  arm. 


Back  of  shoulder 
and   arm ;    outer 
side  of  arm  and 
forearm,   front 
and  baCk. 


Outer  side  of  fore- 
arm, front   and 
back ;  outer  half 
of  hand. 


Inner  side  of  back 
of  arm  and  foie- 
arm  ;  radial  half 
of  hand. 


Forearm  and  hand, 
inner  half. 


Forearm,  inner 
half;  ulnar  distri- 
bution to  hand. 


Skin  of  chest  and 
abdomen  in  bands 
running  around 
and    downwards 
corresponding  to 
spinal  nerves ;  up- 
per gluteal  region. 


SPINAL    LOCALIZATION. 


95 


Segment. 


1st 
lumbar 


2d 
lumbar 


3d 
lumbar 


4th 
lumbar 


5th 
lumbar 


1st  and  2d 
sacral 


3d  to  5th 
sacral 


Muscles. 


Ilio-psoas,  sartorius 
muscles  of  abdomen. 


Ilio-psoas,    sartorius, 
flexors  of  knee   (Re- 
mak),   quadriceps, 
femoris. 

Quadricej^s,  femoris,  in- 
ner rotators  of  thigh, 
abductors  of  thigh. 

Abductors  of  thigh,  ad- 
ductors of  thigh,  flex- 
ors of  knee  (i^'errier), 
tibialis  anticus. 

Outward  rotators  of 
thigh,  flexors  of  knee 
(Ferrier),  flexors   of 
ankle,  extensors    of 
toes. 

Flexors  of  ankle,  long 
flexors  of  toes,  peronei, 
intrinsic  muscles  of 
foot. 

Perineal  muscles. 


Reflex. 


Cremasteric,  1st  to  3d  lum- 
bar ;  striking  inner  thigh 
causes  retraction  of  scro- 
tum. 

Patella  tendon ;  striking 
tendon  causes  extension 
of  leg. 


Gluteal,  4th  and  5th  lum- 
bar ;    striking    buttock 
causes  dimjiling  in  fold 
of  buttock. 


Plantar  ;  tickling  sole  of 
foot  causes  flexion  of  toes 
and  retraction  of  leg. 


Foot  reflex,  Achilles  ten- 
don ;  over  extension  of 
foot  causes  rajnd  flexion, 
ankle  clonus,  bladder  and 
rectal  centres. 


Sensation. 


Skin  over   groin 
and   front    of 
scrotum. 


Outer  side  of  thigh. 


Front  and   inner 
side  of  thigh. 


Inner  side  of  thigh 
and  leg  to  ankle; 
inner  side  of  foot. 


Back  of  thigh,  back 
of  leg,  and  outer 
part  of  foot. 


Back  of  thigh,  leg, 
and    foot,   outer 
side. 


Skin  over  scrotum, 
anus,  perineum, 
genitals. 


For  further  information  on  this  subject  the  student  can  refer 
to  Thorburn,  The  Surgery  of  the  Spinal  Cord. —Seguin,  Pepper's 
System  of  Medicine.— Starr,  Chapters  on  Localization  of  Spinal 
Cord  Diseases,  Familiar  Forms  of  i^ervous  Disease. 


yt)  NERVOUS    DISEASES    AND    INSAJSITY. 


SECTION  III. 
DISEASES  OF  THE  BRAIK 


Acute  Meningitis. 

(Leptomeningitis  Infantum.) 

It  is  by  no  means  confined  strictly  to  the  convexity  ;  it  occurs 
mostly  in  children,  but  may  affect  adults  ;  its  exciting  causes 
are  not  well  known.     Injuries  are  assigned  in  some  cases. 

Symptoms.  It  often  begins  suddenly,  but  there  may  be  pre- 
monitory symptoms  :  Headache,  followed  by  chill,  with  rise  in 
temperature  and  increased  pulse-rate  ;  in  young  children  there 
may  be  convulsions  or  convulsive  twitchings  in  the  muscles  of 
the  face  or  extremities  ;  vomiting  and  nausea  is  a  frequent  symp- 
tom ;  delirium  may  occur.  The  child  lies  in  a  dull  drowsy  con- 
dition, with  distressed  facial  expression  ;  is  irritable  ;  does  not 
like  to  be  disturbed  ;  photophobia  is  almost  constant.  If  the 
base  of  the  brain  becomes  involved,  there  is  strabismus,  which 
at  first  may  be  passing,  and  later  permanent.  Changes  in  the 
jiupils  are  constant ;  rigidity  in  the  back  of  the  neck  ;  later,  the 
stupor  gives  rise  to  coma.  There  may  be  retraction  of  the 
abdomen,  and  paroxysms  of  screaming  ;  as  the  disturbances  of 
nutrition  increase,  by  reason  of  the  pressure  from  hydrocephalic 
fluid,  and  the  disturbances  in  the  vessels ;  the  respiration  becomes 
labored,  and  assumes  the  character  of  Cheyne-Stokes  ;  the 
coma  deepens,  and  death  occurs  quietly  or  with  a  convulsion. 

Meningitis  Purulent. 

(Leptomeningitis  with  Pus.) 

This  is  also  at  times  called  meningitis  of  the  convexity,  but  is 
frequently  generaUzed,  and  even  begins  as  a  basilar  meningitis. 


DISEASES    OF    THE    BRAIN.  97 

Etiology.  In  many  cases  it  is  very  difficult  to  assign  a  cause  ; 
it  occurs  at  all  ages,  in  infants,  young  persons,  and  in  adults  ; 
men  are  most  liable  to  it.  It  occurs  secondary  to  purulent  in- 
flammation of  the  middle  ear  with  bone  disease.  From  injuj-ies 
to  the  bones  of  the  skull  ;  after  erysipelas,  pneumonia,  etc.  ; 
from  disease  of  the  parts  about  the  nose,  eyes,  and  head. 

Symptoms.  It  is  generally  sudden  in  its  onset ;  a  chill,  fever, 
irregular  in  type  ;  severe  headache  ;  delirium ;  vomiting  may 
occur  ;  the  pain  may  be  referred  to  any  part  of  the  head  ;  light 
and  noise  are  distressing  ;  there  may  be  disturbances  of  speech  ; 
aphasia ;  the  headache  may  be  intense,  and  in  children  give 
rise  to  screams  ;  strabismus,  sluggish  or  fixed  pupils  ;  muscular 
twitchings  may  occur  ;  there  may  be  paralysis  if  large  accumu- 
lations of  pus  occur  in  the  motor  areas  so  as  to  cause  pressure  ; 
in  children  there  may  be  grinding  of  the  teeth  and  trismus  ;  the 
mode  of  death  is  the  same  as  in  the  other  varieties  of  meningitis. 

Pathological  Anatomy.  In  purulent  leptomeningitis  the 
meshes  of  the  pia  are  filled  with  pus,  especially  along  the 
vessels  ;  the  process  may  be  most  intense  at  the  convexity  or 
base  if  it  is  the  result  of  middle  ear  disease  ;  the  pus  from  the 
ear  often  finds  its  way  along  the  fiftli  or  the  auditory  nerve,  and 
consequently  the  base  of  the  brain  is  first  and  most  extensively 
affected.  In  leptomeningitis  infantum  there  are  often  no  definite 
changes  discoverable  after  death  except  the  presence  of  exuded 
white  corpuscles,  anaemia,  light -ffidema  ;  this  may  be  the  result 
of  the  rapidly  fatal  termination  in  some  cases. 

Prognosis  is  unfavorable  in  all  these  cases. 

Treatment.  At  present  treatment  gives  no  favorable  results. 
Morphia  to  relieve  the  pain  is  indicated. 

Meningitis  Tubercular. 

Etiology.  The  tubercular  diathesis  and  a  neuropathic  con- 
stitution ;  it  occurs  among  the  rich  as  well  as  the  poor  ;  it  is 
most  frequent  between  the  ages  of  2  and  10  years  ;  males  are 
more  frequently  affected. 

Symptoms.  As  premonitory  symptoms,  general  indisposition, 
slight  headache,  loss  of  appetite  and  flesh,  constipation,  etc.; 
7 


08  NERVOUS    DISEASES    AND    INSANITY. 

this  may  exist  for  weeks  before  pronounced  symptoms  appear. 
The  symptoms  vary  very  much  in  different  cases  :  there  may 
be  a  chill  ;  severe  headache  ;  photophobia  ;  a  rise  of  tem- 
perature ;  vomiting  may  occur  ;  indisposition  to  move  ;  there 
may  be  spasmodic  twitchings  in  the  muscles  of  the  face  or  ex- 
tremities ;  there  soon  occur  lancinating  pains  in  the  head,  during 
which  the  child  screams  or  shrieks  out,  or  moans  and  tosses 
about.  The  pupils  may  show  no  change  at  first,  but  soon  there 
are  inequalities  and  sluggishness  in  the  light  reactions  with 
spontaneous  oscillations  ;  later,  the}^  are  fixed  ;  there  is  now 
passing  paresis  of  some  eye  muscles,  so  that  there  is,  at  times, 
strabismus  ;  later,  it  is  constant.  There  are  now  retraction  of  the 
head  and  rigidity  of  the  muscles  of  the  neck  ;  the  face  is  dusky, 
and  there  is  stupor  from  which  the  child  is  with  difficulty 
aroused.  The  abdomen  may  or  may  not  be  retracted  ;  light 
and  noise  become  more  and  more  intolerable  ;  the  temperature 
may  run  high.  There  may  be  delirium,  but  it  is  not  common. 
Optic  neuritis  may  be  found.  As  the  disease  progresses  convul- 
sions may  occur  ;  and  later,  coma  and  difficult  respiration  with 
frequent  irregular  and  weak  pulse  close  the  scene. 

Prognosis.    Unfavorable. 

Pathological  Anatomy.  The  pia  is  studded  more  or  less 
thickly  with  tubercular  nodules,  especially  over  the  base  ;  they 
surround  the  bloodvessels  of  the  pia  and  even  those  entering  the 
brain  ;  there  is  some  slight  oedema  with  fibro-purulent  deposit. 
The  internal  hydrocephalus  which  is  present  explains,  in  part, 
some  of  the  symptoms. 


Chronic  Hydrocephalus. 

(Internal.) 

Etiology.  Is  not  clear.  Hereditary  predisposition  appears  to 
play  some  part ;  congenital  syphilis  is  believed  to  have  a  causa- 
tive influence  ;  several  children  born  in  the  same  family  may 
be  hydrocephalic  ;  traumatism  to  the  mother  may  play  a  part 
in  causing  it.  Bad  hygienic  conditions.  It  may  be  caused  by 
tumors  of  the  cerebellum  and  its  vicinity  pressing  on  the  vena 


DISEASES    OF    THE    BRAIN.  99 

galeni.      It  usually  begins  just  before  or  soon  after  birth  ;  it 
may  be  preceded  by  an  acute  attack. 

Symptoms.  Convulsions,  rolling  of  the  eyes  about  and  crying, 
are  often  observed  just  after  birth  ;  later  the  head  is  observed 
to  be  growing  larger  ;  but  frequently  no  special  symptoms  are 
observed  until  the  child  is  several  months  old,  when  the  head 
is  found  to  be  growing  out  of  proportion  to  the  body  ;  the 
fontanelles  remain  unclosed,  and  the  child  begins  to  have  a 
peculiar  way  of  rolling  the  eyes  about.  Fluid  gradually  in- 
creases in  the  ventricles,  widening  the  skull  at  all  parts  ;  the 
frontal  bones  push  forward,  and  the  head  sometimes  becomes 
enormous.  The  child  is  dull  and  stupid,  and  as  the  pressure 
becomes  greater  the  optic  nerves  may  be  so  injured  that  sight  is 
much  impaired,  or  lost.  The  disease  is  almost  always  fatal,  but 
the  child  may  live  a  long  time.  When  it  remains  slight  and  its 
progress  is  arrested,  it  is  not  incompatible  with  great  mental 
power. 

Cerebral  Hemorrhage. 

Etiology.  Some  persons  appear  predisposed ;  the  disease  occurs 
usually  after  40  years  of  age  ;  it  is  more  frequent  in  men  ;  any- 
thing which  tends  to  produce  degeneration  and  disease  of  the 
cerebral  arteries  predisposes  to  it.  Disease  of  the  cerebral  arte- 
ries is  the  prime  cause.  Under  these  circumstances  any  great 
increase  in  the  arterial  tension  may  cause  rupture  of  the  vessel. 

Symptoms.  The  attack  is  frequently  ushered  in  without  any 
warning ;  in  other  cases  there  are  premonitory  symptoms  : 
dizziness,  headache,  numbness  in  the  extremities  on  one  side, 
mistakes  in  talking  or  writing,  irritability.  In  the  simplest 
attack  the  person  suddenly  falls,  or  rather  slowly  drops  down, 
is  confused,  but  may  not  lose  consciousness  ;  or  if  he  does,  it 
is  only  momentary,  there  is  more  or  less  paralysis  on  one  side. 
In  the  more  severe  attack  he  loses  consciousness,  falls,  breathes 
heavily  ;  face  is  flushed,  dusky,  and  swollen,  profuse  perspiration 
breaks  out  all  over  the  body  ;  the  respiration  becomes  puffy  ; 
the  arteries  throb  ;  the  conjunctiva  is  injected  ;  the  lids  closed  ; 
the  person  lies  in  a  heap,  as  it  were.  If  the  extremities  are 
picked  up,  it  will  be  found  that  they  drop  heavily  when  let  go, 


100  NERVOUS    DISEASES    AND    INSANITY. 

but  much  more  so  on  oue  side  than  on  the  other — the  paralyzed 
side.  Immediately  after  the  attack,  the  temperature  is  lowered, 
and  in  cases  which  die  in  a  few  hours  it  remains  low.  If  death 
does  not  take  place  soon,  there  is  a  rise  in  the  temperature,  and 
if  the  condition  does  not  progress  favorably  the  temperature 
keeps  rising  until  it  may  reach  106°  or  108°  F.  before  death. 
In  the  cases  which  progress  favorably  the  elevation  in  tempera- 
ture subsides  in  oscillations  to  the  normal.  There  is  in  all  cases 
of  severe  hemorrhage  a  turning  of  the  eyes  and  head  (conjugate 
deviation)  to  the  side  of  lesion  and  away  from  the  paralyzed  side. 
If  recovery  from  the  immediate  symptoms  occurs  the  person  is 
found  paralyzed  on  one  side— arm,  leg,  and  lower  facial  muscles 
— Hemiplegia.  If  the  hemorrhage  occurs  so  as  to  injure  the  sen- 
sory tract  in  the  posterior  part  of  the  internal  capsule,  there  will 
be  either  permanent  or  passing  hemiansesthesia. 

If  the  paralj^'sis  is  on  the  right  side,  there  may  be  aphasia. 
After  a  short  time  the  person  may  be  able  to  walk  about ;  the 
paralyzed  extremities  become  stiff  (early  rigidity),  the  joints 
are  swollen  and  painful,  the  circulation  is  impaired ;  this 
early  rigidity  gives  place  to  a  certain  amount  of  contracture 
(late  rigidity).  The  reflexes  on  that  side  are  exaggerated. 
No  muscular  wasting  takes  place  ;  and  the  electrical  reactions 
are  not  changed.  Very  exceptionally  an  acute  muscular  wast- 
ing may  occur ;  I  have  met  one  case  of  the  kind  ;  it  is  due  to  a 
secondary  lesion  in  the  anterior  horns  of  the  spinal  cord.  It 
occasionally  happens  that  the  onset  of  a  cerebral  hemorrhage  is 
accompanied  with  convulsions  ;  this  is  the  case  when  the 
hemorrhage  breaks  into  the  ventricle  or  perforates  the  cortex, 
so  that  the  blood  is  poured  out  into  the  base  of  the  brain. 
Sufferers  from  cerebral  hemorrhage  rarely  recover  their  former 
mental  vigor;  they  are  emotional,  unable  to  do  mental  w^ork, 
and  in  some  cases  there  are  marked  mental  enfeeblement  and 
even  dementia.      • 

Pathological  Anatomy.  The  greatest  number  of  hemorrhages 
occur  in  the  corpus  striatum  and  its  neighborhood.  Charcot 
and  Bouchard  years  ago  pointed  out  that  miliary  aneurisms 
could  be  found  in  nearly  all  these  cases  ;  a  form  of  periarteritis 
is  the  condition  which  leads  to  the  formation  of  these  aneurisms. 


DISEASES    OF    THE    BRAIN.  101 

Atheromatous  changes  in  tlie  vessels  may  also  lead  to  rupture. 
It  is  believed  that  primary  fatty  degeneration  of  the  vessels  is 
the  cause  of  the  rupture  and  hemorrhage  in  young  persons. 
After  the  hemorrhage  has  destroyed  the  motor  fibres  in  the  in- 
ternal capsule,  a  secondary  degeneration  downwards  takes  place 
in  the  anterior  pyramid  in  the  medulla  ;  and  in  the  direct  and 
crossed  pyramidal  tract  in  the  spinal  end,  this  degeneration  in 
the  cord  is  associated  with  the  contracture  and  the  exaggerated 
reflexes. 

Prognosis.  Depends  upon  the  extent  of  the  hemorrhage  ;  a 
study  of  the  temperature  will  be  found  of  service  in  all  cases 
where  the  hemorrhage  is  at  all  extensive.  Permanent  hemi- 
plegia is  the  result. 

Treatment.  The  clothing  should  be  loosened,  and  the  head 
placed  in  an  easy  position.  Dr.  A.  A.  Smith  has  recently  sug- 
gested depressing  the  head  and  raising  the  lower  extremities 
and  trunk,  so  as  to  cause  rapid  flow  of  blood  to  the  brain,  with 
the  idea  of  rapid  coagulation  of  extra vasated  blood,  and  closure 
of  the  vessel.  He  has  also  proposed  lowering  the  arterial  ten- 
sion by  the  use  of  inhalations  of  nitrite  of  aniyl,  nitro-glycerine, 
by  the  mouth  or  hypodermically.  Gelsemin  and  other  vascular 
depressants  can  be  used.  This  method  of  treatment  is  opposed 
by  many  good  authorities.  The  contracture  which  occurs  as  a 
late  symptom  can  best  be  ameliorated  by  massage  and 
electricity. 

Occlusion  of  Vessels. 

(Embolic  Closure.    Thrombosis.   Endarteritis.    Thrombosis 
of  Cerebral  Sinuses.) 

Etiology.  Valvular  disease  of  the  heart,  with  fibrinous  de- 
posits, which  may  be  washed  off"  into  the  circulation  ;  absorp- 
tion of  foreign  material,  like  blood-clots,  etc.,  from  injuries  of 
all  kinds  ;  portions  of  morbid  growths,  which  may  be  detached 
and  enter  the  circulation  ;  disease  of  the  bloodvessels,  which 
narrows  their  calibre  (endarteritis),  or  roughens  the  internal 
surface  (atheroma),  and  gives  rise  to  a  tendency  to  the  deposit 
of  fibrin  at  this  point  ;   altered  conditions  of  the  blood  as  the 


102  NERVOUS    DISEASES    AND    INSANITY. 

result  of  exhausting  diarrhoea,  and  other  wasting  diseases. 
EmboHsm  is  more  common  in  the  young ;  thrombosis  and 
hemorrhage  in  the  aged.  Symptoms  of  emboUc  closure  of  an 
artery  are  very  similar  to  those  observed  in  cerebral  hemor- 
rhage ;  in  fact,  it  is  frequently  impossible  to  make  a  diflferential 
diagnosis  ;  the  loss  of  consciousness  is  usually  not  as  great  in 
embolism,  but  as  all  degrees  of  loss  of  consciousness  occur  in 
cerebral  hemorrhage,  depending  upon  the  extent  of  the  hemor- 
rhage and  its  location,  this  is  not  worth  much  as  a  differential 
point ;  the  presence  of  decided  valvular  disease  of  the  heart 
would  be  of  more  value,  but  even  this  does  not  make  a  positive 
differential  diagnosis,  as  a  rupture  of  a  cerebral  vessel  is  just  as 
likely  to  occur  in  such  a  case.  If  the  vessel  plugged  be  large, 
such  as  the  middle  cerebral,  which  is  the  most  commonly  closed, 
and  the  left  side  most  frequently,  the  area  of  subsequent  soften- 
ing is  large,  and  we  have  the  hemiplegia  as  found  in  cerebral 
hemorrhage. 

Thrombosis.  The  symptoms  are  said  to  come  on  slowly,  with 
many  premonitor}'  signs,  and  the  paralysis  is  slowly  progressive, 
not  sudden  as  in  hemorrhage  and  emboli.  The  paralysis  is 
hemiplegic  in  type,  and  all  the  other  symptoms  found  in  cere- 
bral hemorrhage  are  present. 

Thrombosis  of  the  cerebral  sinuses  occurs  in  children  usually. 
The  symptoms  are  indefinite  ;  convulsions,  headache,  nausea, 
vomiting,  spasmodic  condition  of  various  muscles  of  the  eyes, 
face,  and  limbs  are  said  to  be  present.  This  must  be  an  exceed- 
ingly rare  condition,  and  it  is  highly  probable  that  some  of  the 
symptoms  which  have  been  attributed  to  thrombosis  of  the 
sinuses  are  due  to  anaemia  from  exhausting  disease,  or  to  an 
early  stage  of  basilar  meningitis. 

Pathological  Anatomy.  Embolic  plugs  are  formed  either  by 
fragments  of  fibrin  washed  off  from  the  diseased  valves  of  the 
heart  or  from  fatty  detrital  masses  from  old  blood  extravasa- 
tions after  injuries  which  in  the  process  of  absorption  enter  the 
general  circulation,  or  possibly  from  small  detached  portions  of 
morbid  growths  in  the  large  cavities  of  the  body  which  en- 
croach upon  and  open  into  a  vessel,  or  from  the  deposit  of 
filDrin  in  an  aneurismal  dilatation,  or  from  broken-down  atliero- 


DISEASES    OF    THE    BRAIN.  103 

matous  patches.     After  the  artery  is  plugged,  softening  of  the 
cerebral  tissue  in  the  area  of  the  arterial  distribution  occurs. 
The  same  occurs  in  thrombosis  and  endarteritis. 


Intracranial  Tumors. 

Kew  growths  may  occur  either  in  the  cerebral  substance 
itself,  or  external  to  it,  in  the  intracranial  cavity. 

Etiology.  Often  there  are  no  indications  as  to  causation.  In 
children  they  often  develop  during  or  very  soon  after  attacks  of 
eruptive  fevers,  measles,  scarlet  fever,  etc.,  evidently  as  the 
result  of  some  disturbance  set  up  in  .the  cerebral  substance,  its 
envelopes,  or  bloodvessels.  They  may  develop  secondary  to 
tumors  in  other  parts  of  the  body  ;  they  are  most  apt  to  occur 
after  tumors  in  the  large  cavities  of  the  body  ;  "  secondary 
growths."  Injuries  are  supposed  to  play  a  part  in  their  devel- 
opment, and  they  may  be  the  means  of  setting  up  the  processes 
wliich  give  rise  to  the  development  of  tubercular  and  syphilitic 
growths.  Bramwell  thinks  they  are  more  common  in  men  than 
in  women.  Tubercular  tumors  are  most  common  in  children 
and  young  persons  ;  syphilitic  tumors  in  early  and  middle  life. 
Sarcomatous  tumors  may  also  occur  in  young  persons. 

Symptoms.  The  general  symptoms  are  headache,  more  or 
less  severe,  often  not  located  ;  frequently  referred  to  a  part  dis- 
tant from  the  seat  of  growth  ;  they  are  most  often  generalized. 
Tumors  developing  in  the  pia  or  dura  are  more  apt  to  give 
rise  to  severe  headache  than  those  developing  in  the  cerebral 
substance. 

Vertigo  occurs  in  almost  all  the  cases,  but  it  is  transient ;  there 
may  be  associated  with  these  vertiginous  attacks  sudden  falling 
to  the  ground,  without  convulsions,  and  very  temporary  loss  of 
consciousness. 

Vomiting  is  a  very  constant  symptom  ;  it  is  sudden  and  explo- 
sive, especially  when  the  growth  is  so  situated  as  to  cause  press- 
ure on  the  medulla. 

Optic  neuritis  is  found  sooner  or  later  in  almost  all  these  cases ; 
it  is  important  to  make  an  ophthalmoscopic  examination  in  all 


104 


NERVOUS    DISEASES    AND    INSANITY. 


cases  of  suspected  brain  tumor,  as  optic  neuritis  may  be  present 
without  any  disturbance  of  vision. 

Optic  nerve  atrophy  may  be  met  with  as  the  result  of  a  pri- 
mary neuritis  in  cases  of  tumors  of  long-standing.  In  all  these 
cases  gradually  faihng  vision  with  later  complete  blindness  will 
occur.  Three  theories  are  offered  to  explain  this  optic  neuritis  : 
1st.  Pressure  and  oedema.  2d.  Descending  neuritis.  3d.  Vaso- 
motor irritation.  It  will  be  unnecessary  to  enter  here  into  the 
explanation  of  these  theories.  There  are  additional  symptoms 
which  depend  upon  the  location  of  the  tumor  :  reference  to  the 
chapter  on  localization  in  diseases  of  the  brain  and  a  study  of 
the  physiological  functions  of  the  brain  will  make  this  clear.     If 


Fjg.  30. 


Fig.  31. 


Ophthalmoplegia  externa  in  a  child 
three  and  a  half  years  old  from  tu- 
mor in  the  mid  brain  showing  the 
double  ptosis  most  marked  on  left 
side.  Personal  case.  (Drawn  from  a 
photograph  by  Dr.  Criado.) 


Showing  the  divergence  of  the  eyeballs 
owing  to  paralysis  of  the  internal  rectus 
on  each  side.  It  can  be  seen  in  the  draw- 
ing that  the  pupil  on  the  left  side  is  larger 
than  on  the  right.  (Drawn  from  a  photo- 
graph by  Dr.  Criado.) 


the  tumor  is  situated  in  the  motor  area,  there  may  be  localized 
spasm,  with  or  without  convulsions  ;  subsequently,  paralysis,  or 
paralysis  coming  on  slowl3^     If  in  the  visual  centres,  disorders 
of  vision,  etc. 
Tumors  in  the  mid  brain,  in  the  neighborhood  of  the  cor- 


DISEASES    OF    THE    BRAIN.  105 

pora  quadrigemina,  give  rise  to  a  combination  of  symptoms 
which  have  been  described  as  ophthahiioplegia  ;  it  is  true  that 
this  condition  may  depend  upon  pathological  changes  other 
than  tumor  ;  such  as  lesions  in  the  nerve  nuclei  or  the  periphery 
of  the  nerves  involved.  The  symptoms  are  double  ptosis  and 
paralysis  of  the  muscles  of  the  eyeball  supplied  by  the  3d  nerve 
on  both  sides.  These  give  the  individual  a  peculiar  appearance. 
The  accompanying  drawing  will  show  clearl}'  this  condition,  and 
for  lack  of  space  I  must  refer  the  student  to  the  articles  referred 
to  for  further  detail. 

Diagnosis.  Gradual  development  of  symptoms  ;  headache, 
vomiting,  epileptiform  seizures,  gradual  onset  of  paralysis 
according  to  motor  areas  involved  ;  optic  neuritis.  If  the  tumor 
is  at  the  base  of  the  brain,  there  is  gradual  involvement  of  cra- 
nial nerves  ;  if  in  the  mid-brain  progressive  paralysis  of  the  3d 
nerve  on  both  sides,  etc. 

Prognosis  is  unfavorable  in  all  cases  of  cerebral  tumor,  except 
in  those  which  are  clearly  syphilitic. 

Treatment.  In  the  syphilitic  tumors  iodide  of  potass,  in 
gradually  increasing  doses.  Iodide  ameliorates  the  symptoms 
in  those  cases  w^hich  are  not  syphilitic,  by  diminishing  the  in- 
ternal hydrocephalus,  which  is  very  likely  to  occur  in  all  these 
cases. 

Trephining  is  now  adopted  in  those  cases  which  present  clear 
localizing  symptoms  ;  it  should  not  be  thought  of  unless  such 
symptoms  are  present. 

Bihliography.— Br amweW,  Tumors  of  the  Brain.— Mills, 
Tumors  of  the  Brain,  Pepper's  System  of  Medicine. — Starr, 
Ophthalmoplegia  Externa,  Journal  Nervous  and  Mental  Dis- 
eases, 1888.— B.  Sachs,  Tumors  of  Mid-Brain,  American  Journal 
Medical  Sciences,  1890.— ,T.  C.  Shaw,  Ophthalmoplegia  Externa, 
Brooklyn  Medical  Journal,  1891.— Weir  &  Seguin,  Contribution 
to  the  Diagnosis  and  Surgical  Treatment  of  Tumors  of  the 
Cerebrum,  American  Journal  Medical  Sciences,  1888. 


106  NERVOUS    DISEASES    AND    INSANITY. 

Abscess  of  the  Brain. 

Etiology.     It  is  most  commonly  caused  by  disease  and  injuries 
of  the  bones  of  the  skull  and  face. 

Symptoms.  From  injuries  to  the  skull  the  symptoms  are  often 
more  or  less  decided.  Headache,  slight  fever,  chills,  vertigo,  nau- 
sea, and  vomiting  ;  there  may  be  attacks  of  localized  spasm  in  the 
face,  arm,  etc.,  according  to  the  location  of  the  lesion,  and  this 
may  give  place  later  to  paralysis  ;  if  the  condition  progresses  to 
a  fatal  termination,  there  are  added  slow  pulse,  delirium  or 
stupor,  dilated  pupils,  coma,  and  death ;  or  the  acute  symptoms 
may  subside,  and  the  abscess  run  a  chronic  course,  when  a 
period  may  follow  in  which  there  are  very  few  symptoms,  if 
any.  In  abscess  the  result  of  disease  of  the  bones  of  the  ear, 
which  is  by  far  the  most  common  cause,  or  of  the  nose  or  face, 
the  symptoms  are  often  obscure  ;  and  there  may  be  no  definite 
symptoms  for  a  long  time  ;  when  they  are  present  they  are 
similar  to  those  observed  in  abscess  from  injury.  In  chronic 
abscess,  headache,  nausea,  and  vomiting,  with  occasionally  fever, 
are  the  most  common  symptoms  ;  they  are  like  those  observed  in 
cerebral  tumor  ;  sometimes  the  terminal  symptoms  only  develop  a 
few  hours  or  days  before  the  fatal  termination.  If  the  abscess 
perforate  the  brain  surface,  there  is  added  a  purulent  meningitis 
with  all  its  symptoms.  If  it  perforate  the  ventricle,  there  are 
almost  surely  convulsions  ;  and  if  life  is  prolonged  a  purulent 
basilar  meningitis.  If  convulsions  occur  in  cases  of  abscess,  it 
may  be  localized  or  general.  The  convul^^ions  and  paralysis  in 
these  cases  depend  upon  the  seat  of  the  abscess,  and  it  is  im- 
portant if  possible  to  locate  them. 

Abscess  may  occur  anywhere  in  the  brain.  It  is  most  com- 
mon in  the  temporo-sphenoid  lobe  and  cerebellum.  In  abscess  of 
the  cerebellum,  there  is  often  a  remarkable  absence  of  symptoms, 
especially  if  located  in  one  lobe,  and  death  often  occurs  very  sud- 
denly from  pressure  on  the  medulla.  I  have  several  times  ob- 
served as  a  symptom  in  these  cases  an  unusual  hunger,  the 
persons  eating  much  more  than  usual  or  complaining  of  hunger 
frequently  ;  death  followed  in  a  few  days  or  weeks. 


DISEASES    OF    THE    BRATN.  107 

Pathological  Anatomy.  The  abscess  may  be  of  any  size. 
The  nerve  elements  are  swollen,  l)reakclown,  forming  a  granular 
soft  mass  mixed  with  abundant  pus-corpuscles  and  some  blood  ; 
the  connective-ti>)Sue  elements  may  be  increased  ;  there  is  always 
an  effort  to  encapsulate  the  abscess,  and  in  the  chronic  cases  the 
abscess  wall  may  be  of  considerable  thickness.  In  some  cases 
of  abscess  from  disease  of  the  middle  ear  a  narrow  long  sinus 
leads  from  the  portion  of  brain  over  the  diseased  bone  to  the 
main  abscess  some  distance  away  like  the  subterranean  passage- 
way into  a  mine.  Around  the  abscess  there  may  be  consider- 
able oedema.  Thrombosis,  purulent  or  not,  of  the  adjacent 
sinuses   is  often  found. 

Prognosis.     Unfavorable  as  a  rule. 

Treatment.  Medicinal  treatment  is  useless.  Trephining 
offers  the  only  prospect  of  cure.  For  this  purpose  it  is  important 
that  there  should  be  localizing  symptoms. 

Disseminated  Cerebro- Spinal  Sclerosis. 

Etiology.  It  is  observed  in  youth  and  middle  age.  It  is  said 
to  follow  blows  ;  intense  emotional  excitement ;  it  develops 
after  the  eruptive  fevers,  measles,  typhoid,  etc. 

Symptoms.  It  may  be  confined  to  the  brain  or  spinal  cord 
alone,  but  most  commonly  it  is  cerebro-spinal,  extending  from 
the  cord  into  the  brain,  or  from  the  brain  into  the  cord.  It 
usually  develops  slowly,  as  jiaresis  in  the  lower  extremities,  or 
in  some  eye  muscle  ;  slow  and  difficult  gait  with  ataxia  and 
parsesthesia.  There  may  be  some  disturbances  in  sensation  in 
places  about  the  extremities  or  body.  Vertigo ;  headache ; 
tremor  on  voluntary  efforts  are  common  ;  speech  is  early  affected, 
it  is  drawling,  slow,  and  indistinct.  Yision  may  be  impaired  ; 
nystagmus  is  almost  constant  in  this  variety ;  tliere  may 
be  apoplectiform  or  epileptiform  seizures,  and  there  are 
contractures  and  rigidity  in  the  limbs ;  the  reflexes  are 
exaggerated  ;  tremor  is  almost  constant,  exclusivel}^  on  voluntary 
motion  ;  it  is  often  so  violent  when  attempting  to  take  any  ob- 
ject that  it  is  almost  impossible  to  do  so.     Its  true  character  is 


108 


NERVOUS    DISEASES    AND    INSANITY. 


brought  out  by  having  the  person  attempt  to  take  a  glass  of 
water  to  the  mouth. 

Trophic  disorders,  bladder  and  rectal  disturbances  are  rarely 
found  in  this  disease.  In  the  spinal  form  the  gait  is  decidedly 
spastic  so  long  as  the  person  can  walk.  When  he  cannot,  the 
legs  are  stiff  and  extended  ;  the  disorder  has  a  wonderful  re- 
semblance to  spastic  paraplegia,  for  which  it  can  be  readily  mis- 
taken. 

Fig    32. 


The  shaded  areas  show  the  scattered  distribution  of  the  sclerosis  at  various  levels 
of  the  spinal  cord  in  a  case  of  disseminated  cerehro-spinal  sclerosis. 

Patholagfical  Anatomy.    Sclerotic  patches  scattered  at  various 
points  without  any  order  throughout  the  cerebro-sninal  axis. 


DISEASES  OF  THE  BRAIN.  109 

Increased  activity  in  the  neuroglia  and  its  cells,  which  soon  be- 
comes so  great  that  the  nerve  tissue  is  injured  ;  the  nerve-fibres 
gradually  disappear,  leaving  the  increased  connective  tissue  with 
its  very  much  enlarged  cells  ;  the  field  of  a  section  at  this  stage 
is  best  seen  by  reference  to  an  illustration,  showing  the  almost 
entire  absence  of  nerve-fibres  ;  a  few  axis  cylinders  are  observed 
and  a  large  number  of  "  spider  cells,"  cells  with  long  processes. 
Treatment.  Tonics  and  alteratives  are  of  service,  but  only  as 
palliative,  as  the  disease  is  steadily  progressive. 

Bibliography.—^.  C.  Seguin,  J.  C.  Shaw,  and  A.  Van  Der- 
vier.— A  Contribution  to  the  Pathological  Anatomy  of  Dissemi- 
nated Cerebro-spinal  Sclerosis,  Journal  Nervous  and  Mental 
Disease,  1878. 

Epilepsy. 

Etiology.  A  neuropathic  family  history  is  to  be  traced  in 
almost  all  the  cases ;  rarely  there  is  direct  transmission.  It 
occurs  most  frequently  for  the  first  time  among  young  persons, 
and  is  most  common  between  10  and  20  years  of  age.  As  ex- 
citing causes,  intense  emotional  excitement,  fright,  irritations 
(peripheral)  of  all  kinds,  from  the  intestinal  tract,  etc.  ;  febrile 
diseases,  injuries  to  the  head,  and  falls  are,  I  believe,  frequent 
exciting  causes  in  these  predisposed  children. 

Symptoms.  Frequently  the  first  attack  is  without  any 
warning ;  the  child  falls  and  is  convulsed.  In  a  propor- 
tion of  the  cases  there  is  a  premonitory  symptom  called  an 
aur£€,  or  "  signal  symptom  "  of  Seguin.  This  may  be  a  localized 
spasm  occurring  in  the  hand,  or  even  in  a  finger,  or  on  the  side 
of  the  face,  and  extending  to  other  parts  (this  is  the  type  of 
Jacksonian  epilepsy),  followed  by  general  convulsion. 

It  is  sometimes  a  question  whether  an  aurse  is  motor  or  sen- 
sory, as  in  some  cases  it  may  be  due  to  a  very  slight  spasmodic 
wave  which  is  not  perceptible  even  in  the  extremities,  but  espe- 
cially in  those  aurae  from  the  viscera,  or  if  they  be  purely  sensory 
as  usually  described  by  the  patient.  The  sensory  aurse  is  the 
most  common  perhaps  ;  it  is  a  feeling  of  tingling  or  numbness 


110  NERVOUS    DISEASES    AND    INSANITY. 

in  the  parts,  which  extends  up  to  the  liead.  They  sometimes 
speak  of  it  as  "  something  running  up  tlie  leg"  or  arm,  or  from 
the  epigastrium.  At  any  rate  it  is  a  peculiar,  indescribable  sensa- 
tion which  these  persons  experience,  apparently  starting  at  some 
point  in  the  body  and  radiating  toward  the  cephalic  extremity. 
I  say  apparently,  because  it  is  really  due  to  central  irritation, 
and  what  is  felt  is  really  a  "  referred  sensation." 

The  aurse  may  be  visual,  when  the  person  sees  flashes  of  light, 
color,  or  even  distinct  objects,  such  as  persons,  animals,  or  even 
scenes  ;  or  they  may  be  auditory,  wdien  he  hears  noises,  voices, 
music,  or  singing  :  or  olfactory,  when  he  smells  odors,  which  are 
disagreeable  usually,  such  as  sulphur,  decaying  animal  matter, 
etc.,  or  they  may  be  pleasant.  There  are  also  psychic  aurse  ; 
the  person  experiences  a  feeling  of  fright  and  dread,  or  he  is  in 
a  confused,  dreamy  state. 

The  attacks  are  of  two  kiniis— petit  mat  and  grand  mal ;  both 
of  these  forms  of  attack  may  occur  in  the  same  person.  The 
attacks  of  petit  mal  are  characterized  by  sudden  loss  of  con- 
sciousness, temporary  in  duration  ;  the  person  stops  in  any  act 
which  he  is  performing,  and  stares  fixedly  before  him.  He  may 
remain  perfectly  quiet,  and  as  soon  as  the  attack  ceases  resume 
the  acts  he  was  performing  before  it ;  or  he  may  jump  up  and 
hurriedly  move  about,  opening  a  door  or  pulling  up  a  curtain, 
etc.,  or  start  to  undress,  or  running  ahead  a  distance  (precursive 
epilepsy).  There  usually  is  a  slight  tonic  spasm  of  the  entire 
body  in  these  attacks,  but  no  clonic  convulsion.  The  attacks 
of  haut  mal  or  grand  mal  are  ushered  in  by  pallor,  by  dilated 
pupils,  often  by  a  loud  piercing  scream,  simultaneous  with  loss 
of  consciousness,  falling  to  the  floor,  tonic  convulsions.  The  face 
now  becomes  livid;  clonic  convulsions  succeed  the  tonic;  the 
head  and  eyes  are  often  turned  to  one  side  ;  the  arms  and  legs 
are  thrown  about  in  all  directions  ;  there  is  frothing  at  the 
mouth  ;  biting  of  the  tongue,  which  colors  the  saliva  with  blood ; 
urine  is  passed ;  respiration  is  difficult  and  deep.  Then  there  is 
a  period  of  cessation  of  all  the  symptoms  ;  after  which  the  per- 
son may  fall  into  a  deep  sleep.  In  some  cases,  this  convulsion  is 
soon  succeeded  by  another,  and  there  may  be  any  number  of  at- 
tacks following  one  another — constituting  "status  epilepticus" 


DISEASES    OF    THE    BRAIN.  Ill 

—during  which  the  temperature  rises  very  high  ;  and  in  some 
cases  the  person  is  found  paralyzed  on  one  side  after  tlie  attacks 
cease— post-epileptic  paralysis— from  which  he  recovers  himself. 
In  other  cases  the  attacks  are  characterized  entirely  by  psychic 
disturbances  ;  the  person  performs  strange  acts,  like  undressing 
himself  in  the  street,  exposing  his  person  or  performing  other 
unseemly  acts  ;  or  he  may  even  commit  crimes,  such  as  break- 
ing things,  or  killing  his  own  children  or  other  people  ;  or  he 
may  shout  and  sing,  and  have  a  true  maniacal  seizure.  After 
the  attacks  of  grand  mal^  he  always  complains  of  being  sore  in 
the  muscles,  owing  to  their  convulsive  action  ;  and  there  are 
frequently  small  ecchymotic  spots  under  the  skin. 

Prognosis.  This  is  a  chronic  condition.  Some  cases  are  very 
much  benefited  by  treatment,  and  in  a  few  cure  possibly  occurs. 

Treatment.  The  most  successful  is  the  use  of  bromides,  given 
cautiously  and  watched,  increasing  the  dose  gradually.  Avoid 
stupefying  the  patient.  The  bromide  should  be  given  between 
meals,  in  water,  or  Yichy,  as  recommended  by  Seguin.  Tonics 
are  indicated  in  these  cases,  and  quinine  is  the  best,  in  small 
doses  ;  or  small  doses  of  arsenic,  cod-liver  oil,  and  nutritious 
food  ;  if  there  is  a  tendency  to  indigestion,  pepsin  may  be  given. 
In  those  cases  where  a  study  of  the  convulsive  seizure  or  sen- 
sory aura  giyes  evidence  of  a  localized  lesion,  and  in  all  cases 
due  to  fracture  of  the  skull,  the  question  of  trephining  may 
have  to  be  considered. 

5^6Ko(/rap%.  —  Go wers,  Epilepsy,  London,  1881. —  Seguin, 
Opera  Minora.— Seguin,  Early  Diagnosis  in  some  Diseases  of  the 
Nervous  System,  Boston  Medical  and  Surgical  Journal,  1891.— 
Hare,  Epilepsy,  Philadelphia,  1890. 

Paralysis  Agitans 

Is  a  disease  of  advanced  life  ;  men  are  most  frequently  affected 
by  it.  It  is  evidently  connected  with  degenerations  of  advan- 
cing years. 

Symptoms.  It  may  begin  slowly  or  somewhat  suddenly  ; 
there  may  be  some  pains  in  the  extremities,  insomnia,  and  irri- 


112 


NERVOUS    DISEASES    AND    INSANITY. 


tability  ;  but  these  are  frequently  absent.  The  disease  usually 
begins  as  a  trembling  in  the  muscles  of  one  hand  ;  at  first  it 
ma}^  be  intermittent,  but  later  it  is  constant,  except  when  asleep. 
The  tremor  is  a  slow  rhythmical  movement ;  the  attitude  of  the 

Fig.  33. 


Showing  the  attitude  in  paralysis  agitans.     (Drawn  from  an  illustration  by 
Charcot,  Maladies  du  Systems  Nerveux,  tome  i.) 

hand  is  peculiar,  the  wrist  is  slightly  flexed,  the  fingers  bent 
downwards,  the  thumb  lightly  opposed  to  the  index  and  middle 
finger.    The  tremor  may  for  a  long  time  be  confined  to  one  arm, 


DISEASES    OF    THE    BRAIN.  118 

or  extend  to  the  leg  of  the  same  side  ;  it  is  never  so  marked 
in  the  lower  extremity  as  in  the  upper  ;  the  head  may  also  be 
involved,  and  the  tremor  may  even  begin  in  the  head.  Dr.  Ami- 
don  showed  a  case  of  the  kind  before  the  Kew  York  Neurological 
Society  some  years  ago,  and  I  have  seen  a  few  instances  of  it. 
The  speech  is  often  slow,  and  as  the  disease  progresses  muscular 
rigidity  occurs  to  a  certain  extent,  especially  in  the  muscles  of 
the  back,  so  that  the  spine  is  more  or  less  fixed  ;  this  gives  rise 
to  a  peculiar  bent-forward  attitude,  the  head  is  inclined  on  the 
chest,  in  speaking  the  person  turns  the  eyes  up.  The  gait  is 
characteristic  :  the  person  rises  very  slowly  and  with  some  dif- 
ficulty from  his  seat.  It  is  found  that  some  persons  show  a  ten- 
dency to  run  forwards,  and  Charcot  found  that  x)ulling  on  the 
back  of  the  dress  of  one  of  his  patients  caused  a  tendency  to  re- 
tropulsion.  There  are  at  times  uncomfortable  sensations  about 
the  body;  but  one  which  is  almost  constant  is  a  sensation  of  heat 
and  burning,  the  person  sleeps  with  very  little  covering.  As  the 
disease  progresses  the  health  fails,  the  mind  grows  weaker,  bed- 
sores may  form,  and  death  is  caused  by  some  intercurrent  dis- 
ease ;  and  from  my  own  experience,  Bright's  disease  is  the  most 
common.  But  death  may  occur  from  pneumonia,  j)leuritis,  etc. 
There  are  occasionally  observed  cases  of  this  disease  without  the 
trembling.  One  case  of  the  kind  has  come  under  ray  observa- 
tion, through  the  kindness  of  Dr.  A.  J.  C.  Skene.  The  charac- 
teristic gait,  attitude,  propulsion,  burning  sensation,  etc.,  were 
all  present  in  a  typical  form,  but  there  was  no  tremor. 

Pathological  Anatomy.  Nothing  definite  is  known  of  the 
changes  which  give  rise  to  these  symptoms. 

Prognosis.     It  is  a  slowly  progressive  disease. 

Treatment.  Is  only  palliative ;  attention  to  the  general 
health,  light  nutritious  diet.  Tonics  may  be  given  ;  a  host  of 
remedies  have  been  given,  but  they  are  all  useless.  Morphia 
may  give  some  relief  to  the  burning.  Small  doses  of  hyoscya- 
mine,  ^^^  grain,  two  or  three  times  a  day,  diminish  the  tremor 
arid  give  relief.  There  sliould  be  freedom  from  work  and  anxiety. 
If  there  is  insomnia,  bromide  soda,  urethan,  sulphonal,  etc.,  may 
be  used  at  intervals. 


Ill  NERVOUS    DISEASES    AND    INSANITY. 

Fig.  34. 


Showing  position  of  hand  in  paralysis  agitans.     (After  Charcot.) 

Bibliography.— Cheii'cot,  Diseases  of  the  Nervous  System. — 
Peterson,  :N'.  Y.  Medical  Journal,  1890. 

Spastic  Hemiplegia  in  Children. 

Etiology.  Most  of  the  cases  occur  in  the  first  three  years  of 
life  ;  but  they  may  occur  even  at  a  later  period.  The  disease  is 
caused  possibly  by  abnormal  conditions  of  the  mother  during 
pregnancy.  Accidents  and  injury  to  the  mother  are  possible 
causes.  Sinkler  lias  insisted  upon  difficult  and  abnormal  labors 
as  a  cause  ;  injuries  to  the  head  ;  the  infectious  diseases. 

Symptoms.  It  often  begins,  just  after  birth,  with  convulsions, 
either  local  or  generalized  ;  there  may  be  a  series  of  convulsions, 
coming  on  at  intervals  and  lasting  several  days,  with  hemiplegia, 
which  remains  permanent;  or  the  child  may  die  within  the  first 
24  or  36  hours.  The  disease,  when  it  occurs  later  in  life,  is  usu- 
ally ushered  in  by  convulsions,  with  or  without  fever.  After  the 
convulsions  cease  the  child  is  found  hemiplegic  ;  the  face  is  not 
alwa^'s  affected,  but  when  it  is,  the  disease  often  soon  disappears 
almost  entirely ;  the  hemiplegia  is  usually  not  complete,  so  that 
the  child  soon  learns  to  w^alk,  although  awkwardly.  As  tlie 
child  grows  the  paralyzed  side  does  not  develop  as  fully  as  the 
other  ;  the  bones  may  be  shorter  ;  in  the  majority  of  cases  con- 
tracture takes  place  to  a  greater  or  less  degree  ;  the  arm  may  be 
flexed,  the  hand  flexed,  and  the  fingers  drawn  in.  The  reflexes 
are  exaggerated  ;  there  is  considerable  motion  in  the  parts,  and 
the  leg  is  never  so  much  afffected  as  the  arm.  In  some  cases 
there  is  very  slight  contracture  ;  sensation  is  usually  not  affected  ; 
the  electrical  reactions  of  the  muscles  are  normal.     In  quite  a 


DISEASES    OF    THE    BRAIN.  115 

proportiou  of  these  cases,  sooDer  or  later,  epileptic  convulsions 
occur,  and  the  convulsive  seizures  may  be  confined  entirely  to 
the  paralyzed  side  ;  but  in  the  majority  of  cases  there  is  a 
general  convulsion,  with  loss  of  consciousness,  etc.,  and  the 
paralyzed  side  is  most  convulsed.  In  a  considerable  propor- 
tion of  these  cases  there  is  imbecility.  It  is  not  uncommon 
to  meet  with  post-hemiplegic  trembling,  posthemiplegic  chorea, 
and  athetosis.  The  hemiplegic  trembling  may  be  present  only 
when  the  muscles  are  put  on  the  stretch ;  or  it  may  be  continu- 
ous during  the  waking  hours  ;  it  is  not  made  worse  by  motion, 
as  in  disseminated  sclerosis,  but  is  rather  diminished,  or  en- 
tirely stopped  by  voluntary  efforts  ;  at  least,  when  first  made,  in 
this  respect  like  the  trembling  in  paralysis  agitaus.  The  tremor 
is  not  so  fine,  steady,  and  rhythmical  as  in  paralysis  agitans. 
The  choreic  movements  are  mainly  confined  to  pronation  and 
supination  of  the  forearm,  and  to  flexion  and  extension  of  the 
elbow-joint.  The  movements  are  disorderly  and  irregular,  and 
cease  during  sleep. 

Athetosis  is  a  condition  of  constant  motion  in  the  fingers  and 
hand.  The  patient  is  unable  to  keep  them  in  any  fixed  position  : 
lives  for  years,  and  dies  of  some  intercurrent  disease,  of  which 
phthisis  is  one  of  the  most  common  forms. 

There  is  also  observed  in  children  a  spastic  paraplegia.  The 
S3^mptom  may  date  from  birth,  but  it  frequently  is  not  observed 
until  some  time  afterward,  when  it  is  found  that  the  child,  whose 
legs  are  rigid,  does  not  move  them  freely,  and  learns  to  walk  late, 
when  it  presents  all  the  symptoms  of  spastic  paraplegia  in  the 
adult.  There  is  also  a  bilateral  spastic  hemiplegia.  This  is 
nothing  more  or  less  than  a  hemiplegia  on  both  sides,  due  to  a 
lesion  in  the  motor  tract  of  each  hemisphere,  with  secondary 
degenerations  in  the  lateral  columns.  The  subjects  of  this  con- 
dition are  usually  imbeciles. 

Pathological  Anatomy.  It  is  claimed  by  Striimpell  that  a 
large  proportion  of  these  cases  are  due  to  an  acute  polioenceph- 
alitis, analogous  to  the  poliomyelitis  of  the  anterior  horns  in 
children.  This  view  is  not  accepted  by  all  writers.  The  fact  is 
the  lesions  which  give  rise  to  this  condition  are  not  fully  made 
out ;   they  evidently  depend   upon  a  variety  of  pathological 


116 


NEKVOUS    DISEASES    AND    INSANITY. 
Fig.  35. 


Spastic  hemiplegia,  left  side;  showing  the  contracture;  arrests  of  development ; 
epilepsy,  and  imbecility.    (Drawn  by  Mrs.  Shaw  from  photograph  by  Dr.  Duryea.) 


DISEASES    OF    THE    BRAIN.  117 

changes.  Meningeal  hemorrhages,  resulting  from  rupture  of 
the  vessels  during  a  difficult  labor,  with  perhaps  a  weak  con- 
dition of  the  vessels,  owing  to  nutritional  disturbances  during 
intra-uterine  life,  are  undoubtedly  a  frequent  cause  of  these 
cases  occurring  just  or  soon  after  labor,  or  as  the  result  of  injury 
in  later  life,  or  from  fatty  changes  in  the  vessels  during  the 
eruptive  fevers.  The  hemorrhage  gives  rise  to  convulsion.s  and 
ultimate  changes  in  the  brain,  with  atrophy. 

The  loss  of  substance  in  some  cases  is  very  great,  and  fre- 
quently contined  to  the  motor  areas. 

Polioencephalitis  may  occur  in  some  cases  ;  the  association  of 
high  temperature  might  lead  to  such  a  diagnosis ;  but  it  is  very 
probable  that  a  certain  amount  of  encephalitis  is  set  up  in  those 
cases  of  meningeal  hemorrhage. 

In  a  few  cases  I  have  had  an  opportunity  of  following  to  an 
autopsy  :  in  three  of  them  one  entire  hemisphere  was  atro- 
phied to  one-third  its  normal  size  ;  in  one  the  loss  of  substance 
was  confined  to  the  motor  zone  and  temporal  lobes,  the  result 
evidently  of  hemorrhage  from  injury  to  the  skull. 

Treatment  is  of  very  little  use  except  to  relieve  the  contrac- 
ture by  friction. 

Bibliography. — McNut,  American  Journal  Medical  Sciences, 
1885.— Ross,  Brain,  1882.— Osier,  Monograph,  1889.— Sinkle'r, 
Medical  News,  1885. — Sachs  and  Peterson,  Journal  Xervous 
and  Mental  Disease,  1890. 

In  the  monograph  of  Osier  and  the  essay  of  Sachs  a  more 
complete  bibliography  will  be  found. 

Cerebral  Localization. 

Only  a  sketch  of  the  subject  can  be  given  here.  A  reference 
to  the  accompanying  diagram  will  show  the  motor  area  for  the 
face,  arm,  and  leg.  Lesions  which  cause  irritation  in  any  of 
these  centres  give  rise  to  localized  convulsion  or  spasm  in  the 
muscles  or  limb  of  which  it  is  the  motor  area.  If  the  lesion  is 
a  destructive  one,  it  causes  paralysis.  If  the  lesion  is  first  irrita- 
tive and  progresses  slowly  to  destruction,  the  spasm  which  at 


118 


NERVOUS    DISEASES    AND    INSANITY 


first  occurs,  gives  place  later  to  slowly  increasing  paralysis  of  the 
part.  In  cases  in  which  localized  convulsion  or  sensory  disturb- 
ances are  the  first  symptom,  "signal  symptom"  (Seguin),  the 
convulsions  may  become  generalized.  It  is  important  to  learn 
which  are  the  parts  first  affected  by  convulsion,  or  Vjy  any  dis- 
turbances of  sensation  so  as  to  locate  the  diseased  area  in  the 
brain.  These  localized  convulsive  seizures  from  brain  disease 
are  often  spoken  of  as  Jacksonian  epilepsy.  If  the  convulsion 
or  disturbed  sensation  begins  in  the  face,  the  lesion  is  in  the  face 
centre  ;  if  in  the  arm,  then  the  lesion  is  in  the  area  for  the  arm, 

Fig.  36. 


1.  Lesion  in  motor  aphasia.  2.  Supposed  location  of  lesions  in  agraphia.  3. 
Motor  area  of  face  and  lips.  4.  Motor  area  of  arm.  5.  Motor  area  of  leg.  6. 
Lesion  in  word  blindness.    7.  Lesion  in  word  deafness.    8.  Lesion  in  hemianopsia. 


etc.  To  be  sure  you  are  correct  about  this,  it  is  necessary  to 
have  a  number  of  seizures,  each  one  beginning  in  the  same  way. 
If  there  are  visual  disturbances,  hemianopsia,  or  word  blindness, 
the  lesion  is  in  the  cuneus  or  angular  gyrus. 


DISEASES    OF    THE    BRAIN 


119 


Aphasia 

May  be  caused  by  lesions  in  several  parts  of  the  brain.  The 
student  must  again  refer  to  the  diagram  (Fig.  3(j)  showing  the 
locations  of  these  lesions.  Lesions  of  the  third  frontal  convolu- 
tion on  the  left  side,  Broca's  convolution,  cause  motor  aphasia, 
loss  of  memory,  for  the  motor  combinations  necessary  to  pro- 
nounce words.  The  person  can  understand  what  is  said  to  him, 
but  cannot  repeat  after  you,  or  speak  himself.  He  can  recog- 
nize things  about  him,  but  cannot  name  them.  He  can  hear 
and  recognize  what  is  said,  but  can  make  no  reply. 

ApraxTa  is  now  used  to  indicate  disturbances  in  the  sensory 
sphere  which  give  rise  to  certain  forms  of  aphasia.     The  sensory 
aphasia.     To  determine  whether  this  form  of  aphasia  exists,  it 
is  necessary  to  observe  if  the  person  recognizes  familiar  objects 
about  him  and  their  uses.     He  may  see  the  objects,  but  1)e  un- 
able to  recognize  them.     He  may  l)e  able  to  see  that  there  are 
letters  in  a  book  or  newspaper,  but  he  no  longer  recognizes  them. 
He  is  unable  to  write,  as  he  has  forgotten  the  appearance  of  the 
letters.     One  of  my  patients,  who  had  a  slight  apoplectiform 
seizure,  told  me,  of  her  own  accord,  that  for  several  days  after- 
wards she  could  see  food  on  her  plate,  but  could  not  recognize 
what  it  was.      The  lesion  giving  rise  to  this  symptom  is  in 
the  ano-ular  gyrus.     This  is  known  as  word  hlindness.     A  simi- 
lar condition''  may  affect  the  auditory  centre.     The  person  is 
no  longer  able  to  recognize  sounds  and  their  meaning,  as  he 
formerly  did.     He  may  hear  the  voice  of  one  speaking,  but  the 
words  uttered  are  to  him  no  longer  intelligible.     He  entirely 
fails  to  appreciate  what  is  said  to  him,  owing  to  the  loss  of 
memory  for  the  sound  of  words,  etc.      This  is  tuord  deafness, 
and  it  is  caused  by  lesions  of  the  posterior  half  of  the  first  and 
second  temporal  convolutions  in  the  left  hemisphere,  in  right- 
handed  persons. 

Agraphia  is  the  loss  of  memory  for  the  motor  combinations 
necessary  for  writing,  as  motor  aphasia  is  the  loss  of  memory 
for  the  motor  combinations  necessary  for  speaking.  The  seat 
of  lesion  is  believed  to  be  in  the  posterior  part  of  the  second 


120 


NERVOUS    DISEASES    AND    INSANITY. 


frontal  convolution.  The  student  must  not  forget  that  in  word 
hlindness  the  person  cannot  write,  but  that  this  inability  is  due 
to  the  loss  of  memory  of  the  appearance  of  the  word. 

Visual  disturbances  of  a  certain  kind  are  caused  by  lesions 
in  the  occipital  lobes,  but  more  especially  in  the  cuneus.  This 
form  of  visual  disorder  is  known  as  hemianopsia,  often  called 
homonymous  hemianopsia  ;  it  is  blindness  in  the  corresponding 
halves  of  the  retina  of  each  eye  (a  reference  to  the  diagram  will 
make  this  plain).  If  the  person  is  looking  straight  forward,  he 
cannot  see  objects  to  the  left  if  the  lesion  is  on  the  right  side  of 
the  brain. 

A  lesion  anywhere  from  the  chiasm  to  the  cuneus  will  cause 
this  symptom,  if  in  the  line  of  the  visual  tract.  If  the  lesion 
is  in  the  cuneus,  there  is  homonymous  hemianopsia.  If  in 
the  neighborhood  of  the  thalamus  so  as  to  interfere  with  the 
sensory  tract  in  the  internal  capsule,  there  may  be  hemian^es- 
thesia.    If  in  the  neighborhood  of  the  crus,  so  as  to  interfere 

Fig.  37. 


Lesioii  of  cuneus  in  hemianopsia. 


with  the  motor  tract,  there  may  be  hemiplegia  and  paralysis  of 
the  third  nerve  on  opposite  side.  These  may  be  very  temporary 
symptoms.     It  has  been  pointed  out  by  Wernicke  and  Seguin 


DISEASES    OF    THE    BRAIN.  1'21 

that   a    symptom    may   be   present   in    some    cases   of   hemi- 
anopsia which  would  differentiate  a  peripheral  from  a  central 

Fig.  38. 


To  show  left  lateral  hemianopsia.  (After  Seguin.)  Lesion  in  right  cuneus. 
1.  Caneus.  2.  Optic  tract  in  internal  capsule.  3.  Corpus  geniculatum  laterals. 
4.  Corpora  quadrigemina,  optic  lobes.    5.  Optic  chiasm. 

lesion;    the    "  hemiopic   pupillary   reaction"   of   Wernicke   or 
''hemiopic  pupillary  inaction"  of  Seguin.     This  symptom  is 


122  NERVOUS    DISEASES    AND    INSANITY. 

very  difficult  of  demonstration,  and  depends  upon  the  insen- 
sitiveness  of  the  retina  on  the  diseased  side.  If  a  pencil  of  light 
is  carefully  thrown  through  the  pupil  upon  the  insensitive  half  of 
either  retina,  it  is  found  that  neither  iris  reacts  ;  hence  "hemi- 
opic  pupillary  inaction,"  if  present,  is  evidence  that  the  lesion 
is  peripheral  to  the  optic  lobes  and  not  central. 

For  more  complete  details  refer  to  the  articles  on  Hemianopsia 
by  Seguin,  Journal  Nervous  and  Mental  Disease,  1886  and  1887. 

Subcortical  Lesions. 

Localization  of  lesions  below  the  cortex  and  above  the  basal 
ganglia  has  only  recently  been  attempted.  This  mass  of  white 
matter,  the  centrum  ovale,  is  traversed  in  all  directions  by  fibres 
of  the  projection,  commissural,  and  association  systems,  bringing 
into  communication  the  various  masses  of  gray  matter.  It  must 
necessarily  follow  that  injury  to  any  of  these  fibres  which  carry 
motor  and  sensory  impressions  and  impulses  would  give  rise  to 
symptoms ;  but  the  investigation  of  these  symptoms  requires 
great  care,  and  it  is  only  ver}'-  recently  that  such  studies  have 
been  undertaken.  There  is  not  sufiicient  clinical  evidence  upon 
which  conclusions  can  be  reached  to  serve  as  a  guide  for  localiza- 
tion of  lesions  in  this  area.  Lesions  of  the  corpus  striatum  and 
lenticular  nucleus  alone  cannot  be  differentiated.  It  is  rare, 
however,  to  have  lesions  strictly  confined  to  these  bodies.  The 
fibres  of  the  internal  capsule  are  very  likely  to  be  involved,  or 
some  other  fibres.  If  the  internal  capsule  is  much  injured,  then 
we  have  paralysis  on  the  opposite  side  of  the  body,  more  or  less 
great  accordins:  to  the  extent  of  the  lesion.  Some  evidence  has 
been  forthcoming  recently'  which  appears  to  show  that  lesions 
in  the  lenticular  nucleus  or  its  neighborhood  may  give  rise  to  a 
set  of  symptoms  which  simulate  very  closely  those  produced  by 
lesions  in  the  medulla  oblongata,  and  known  clinically  as  glosso- 
labio  laryngeal  paralysis  or  bulbar  paralysis.  This  diseased 
condition  of  the  nerve  nuclei  in  the  medulla  has  been  alluded  to 
under  Progressive  Muscular  Atroph}^  and  Lateral  Amyotrophic 
Sclerosis.  This  was  the  only  form  of  glosso-labio  laryngeal 
paralysis  known  until  1872,  when  Joffroy  suggested  that  there 


DISEASES    OF    THE    I5RATX.  128 

might  be  a  ccrelDral  form.  In  1877  Lepine  reported  the  first 
two  cases  of  this  form  of  paralysis  due  to  a  cerebral  lesion 
(Rev.  Mensuelle,  1887).  Kirchoff,  in  1881  (Archiv  f.  Psych.), 
added  another  case  :  a  man  with  apoplectiform  seizures  followed 
by  difficulty  in  swallowing,  saliva  collecting  in  the  mouth,  diffi- 
culty in  protruding  the  tongue,  closure  of  the  glottis  performed 
slowly,  speech  difficult.  Five  months  later  deglutition  is  only 
possible  when  the  head  is  thrown  back,  speech  difficult,  and  saliva 
dribbles  away.  Later,  the  person  is  seized  with  llaccid  hemi- 
plegia on  right  side,  followed  by  convulsions  and  death.  Autopsy 
showed  left  corpus  striatum  a  little  flat ;  right  corpus  striatum  de- 
pressed in  its  posterior  two-thirds  and  softened.  The  correspond- 
ing part  of  the  internal  capsule  is  gra}'.  The  external  third  of 
the  lenticular  nucleus,  the  claustrum,  the  external  capsule,  and 
insula  are  soft,  but  without  discoloration  ;  the  softening  increases 
backwards  in  the  lenticular  nucleus.  Microscopic  examination 
of  the  pons  and  medulla  shows  absolute  integrity. 

In  1884  Drs.  S.  E.  Fuller  and  Wm.  Browning  reported  the  case 
of  a  lady  (N.  Y.  Medical  Record)  who  had  left  hemiplegia  with 
aphasia,  from  which  there  was  entire  recovery.  Subsequently  she 
was  seized  with  an  attack,  followed  at  once  by  inability  to  speak. 
She  could  only  make  an  expiratory  guttural  sound.  "  The  lips, 
tongue,  and  muscles  of  deglutition  were  paralyzed  ;  the  saliva 
flowed  from  whatever  angle  of  the  mouth  was  lowest ;  the  upper 
portion  of  the  facial  nerve  was  intact,  and  pupils  reacted 
normally.  The  tongue  was  quite  motionless.  At  the  autopsy 
two  fresh  clots  of  blood  were  found  in  the  lenticular  nuclei  ex- 
tending into  all  the  divisions  and  tapering  off  posteriorly.  On 
the  right  side,  in  front  of  and  external  to  the  recent  hemorrhage, 
were  the  remains  of  the  former  one.  This  was  in  the  claustrum 
and  external  capsule."  In  1885,  Dr.  B.  Delavan  reported  (X.  Y. 
Medical  Record)  the  case  of  a  man  having  suffered  an  apoplecti- 
form seizure  from  w^hich  there  was  complete  recovery.  A  3^ear 
later  he  had  an  attack  followed  by  marked  hemiplegia,  almost 
total  inability  to  swallow,  and  a  remarkable  change  in  the  quality 
of  his  voice  ;  articulation  impaired.     There  was  no  aphasia. 

A  number  of  similar  cases  have  been  reported  in  the  last  ten 
years.     It  is  not  unfrequently  observed    in   cases  of  cerebral 


124  NERVOUS    DISEASES    AND    INSANITY. 

hemorrhage  or  embolism  that  there  is  a  difficulty  in  speech, 
thick,  indistinct  (not  aphasic),  or  it  may  be  associated  with 
aphasia  and  difficulty  of  swallowing,  which  may  be  of  tempo- 
rary duration.  The  study  of  these  cases,  clinically  and  patholog- 
ically, is  of  importance.  In  1881,  in  a  note  on  the  tendon  reflex 
in  general  paralysis  of  the  insane  (Archives  of  Medicine),  I 
intimated  that  there  was  an  anatomical  lesion  which  gave  rise 
to  the  association  of  disturbances  of  speech  (the  ataxic  paralytic 
form)  and  increased  tendon  reflex,  and  that  it  was  in  these 
cases  apoplectiform  seizures  were  most  common.  Owing  to  an 
unfortunate  accident  to  some  specimens,  I  was  unable  to  demon- 
strate ray  findings  and  ideas  on  the  subject,  except  to  some 
friends.  The  publication  of  these  cases  of  pseudo-bulbar 
paralysis  is  in  support  of  my  observations,  imperfect  as  they 
were.  I  had  observed,  in  autopsies  of  three  or  four  of  these 
general  paralytics  who  had  been  carefully  observed  by  me,  and 
who  suffered  from  frequent  apoplectiform  seizures,  marked 
dementia,  paralytic-ataxic  disorders  of  speech  of  a  very  decided 
character,  and  a  greater  difficulty  in  swallowing  than  is  ordi- 
narily found  in  these  cases,  with  increase  in  the  tendon  reflex  ; 
softened  patches  in  the  corpus  striatum,  and  more  especially 
in  the  lenticular  nucleus  ;  the  fibres  of  the  internal  capsule 
were  also  involved  in  these  softened  spots  ;  they  were  never 
very  large,  and  did  not  appear  to  be  the  result  of  a  hemor- 
rhage, but  a  breaking-down  of  the  tissue.  There  were,  of 
course,  the  other  lesions  generally  found  in  this  disease.  (See 
General  Paralysis  of  the  Insane.)  It  appeared  to  me  that 
these  softened  spots  cut  off,  partially,  fibres  which  are  the 
j)aths  of  communication  between  the  speech  centres  in  the 
cortex  and  the  motor  speech  innervations  in  the  medulla,  thus 
giving  rise  to  the  ataxic  paralytic  disturbances.  The  inter- 
ference with  the  fibres  in  the  internal  capsule  gave  rise  to  the 
secondary  degenerations  in  the  spinal  cord  and  the  increased 
reflexes. 

Ten  years  have  not  changed  my  opinion  on  this  subject : 
that  there  are  certain  cases  of  general  paralysis  of  the  insane 
in  which  these  paralytic  speech  disturbances  depend  upon  a 
lesion  in  the  lenticular  nucleus  or  its  neighborhood.     I  am  well 


DISEASES    OF    THE    BRAIN.  125 

aware,  and  was  ten  years  ago,  that  lesions  had  been  found  in 
the  medulla  oblongata  which  were  believed  to  explain,  and 
probably  did  explain,  some  of  the  disorders  of  speech  ;  but  it 
was  not  the  only  part  of  the  nervous  system  lesions  of  which 
might  cause  these  difficulties  of  speech  (not  aphasic). 

It  appears,  then,  that  lesions  in  the  lenticular  nucleus  or  its 
neighborhood  may  give  rise  to  glosso-labio  laryngeal  paralysis, 
like  that  which  was  long  ago  observed  in  certain  lesions  of  the 
medulla.  The  distinctive  features  are  not  yet  clearly  made  out ; 
in  fact,  the  investigation  of  the  subject  has  just  begun.  In 
the  cerebral  form  there  would  probably  be  a  history  of  one  or 
more  apoplectiform  seizures,  which  are  rare,  if  ever  present  in 
the  bulbar  form.  Emotional  disturbances  and  absence  of 
muscular  atrophy  characterize  the  cerebral  form. 

Lesions  of  the  pyramidal  tract  above  the  decussation  and  in 
the  internal  capsule  cause  hemiplegia  on  the  opposite  side  of 
the  body  ;  the  lower  facial  muscles,  arm,  and  leg  are  paralyzed. 

Lesions  in  the  posterior  part  of  the  internal  capsule,  the 
sensory  tract,  or  the  optic  radiations  of  Gratiolet  cause  hemi- 
ansesthesia  ;  face,  extremities,  mucous  membrane,  taste,  smell, 
are  abolished  ;  hearing  and  sight  are  diminished  ;  there  is 
restriction  of  the  visual  field  and  disturbance  of  color  percep- 
tion (Dyschromatopsie). 

The  degree  of  aneesthesia  varies  ;  the  person  cannot  feel  prick- 
ing, pressure  on  the  parts,  or  the  faradic  current,  and  is  unable 
to  tell  the  position  in  which  the  extremities  may  be  placed. 

The  visual  tract  to  the  cuneus  is  in  this  neighborhood,  so  that 
it  may  be  injured,  when  there  would  be  in  addition  hemianopsia. 

Lesions  of  the  thalamus  give  rise  to  no  symptoms  which, 
from  our  present  knowledge,  make  them  recognizable.  Le- 
sions of  considerable  size  may  cause  symptoms  such  as  hemi- 
plegia, hemiansesthesia,  or  hemianopsia,  but  these  would  each 
depend  upon  the  pressure  or  injury  of  neighboring  parts  ;  the 
peduncular  tract  in  the  internal  capsule,  the  posterior  part  of 
the  internal  capsule,  or  the  optic  radiations  of  Gratiolet  would 
be  injured. 

Lesions  of  the  Corpora  duadrigemina  or  the  Quadrigeminal 
Region  or  the  Mid  Brain.    Until  within  the  last  few  years,  it 


126  NERVOUS    DISEASES    AND    INSANITY. 

has  been  impossible  to  diagnose  lesions  in  this  region.  At  pres- 
ent we  are  in  possession  of  some  clinical  facts  which  make  tliis 
possible,  in  some  cases  at  least.  Hemorrhage  into  this  portion 
of  the  brain  is  rare.  Tumors  occur,  but  not  frequently. 
Lesions  are  rarely  confined  strictly  to  the  quadrigeminal  bodies. 
Formerly  they  were  supposed  to  have  something  to  do  with 
vision  ;  recent  clinical  observations  appear  to  disprove  this 
view.  In  a  recent  publication  by  Xothnagel,  on  the  diagnosis 
of  diseases  of  the  corpora  quadrigemina,  he  expresses  himself  as 
follows  :  The  total  substitution  of  the  corpora  quadrigeminal 
tissue  by  a  tumor  results  in  defective  co-ordination.  An  un- 
steady reeling  carriage  during  locomotion  and  station  is  a  con- 
stant symptom ;  and  this  symptom  depends  upon  the  affection 
of  the  corpora  quadrigemina  themselves,  not  upon  other  parts  of 
the  brain  being  involved,  nor  upon  secondary  conditions,  such 
as  hydrocephalus.  This  disturbance  of  co-ordination  is  shown 
by  an  unsteadiness  in  walking  and  standing,  a  stumbling  and 
reeling,  altogether  comparable  to  the  staggering  of  a  drunken 
man,  or  to  that  which  appears  in  disease  of  the  cerebellum  or 
its  vermiform  process.  It  has  no  similarity  to  tlie  ataxia  of 
tabes.  The  upper  extremities  are  completely  free  ;  only  the  gait 
and  equilibrium  of  the  body  while  standing  are  impaired.  This 
unsteadiness  of  gait  is  not  pathognomonic,  as  it  occurs  from 
lesions  in  other  parts  of  the  brain— the  appearance  of  paralysis 
in  the  territory  of  the  ocular  nerves,  especially  the  oculo-motor. 
The  oculo-motor  nerve  troubles  are  to  be  referred  to  the  nuclei 
and  radical  fibres  of  those  nerves,  not  to  the  ganglia  of  the  cor- 
pora quadrigemina.  He  thinks  that  the  existence  of  ophthalmo- 
plegia is  of  great  importance  as  a  diagnostic  symptom  of  lesion 
in  the  quadrigeminal  region  when  associated  with  other  symp- 
toms, particularly  the  uncertainty  of  gait  above  described.  A 
special  characteristic  of  the  ophthalmoplegia  in  these  cases  is  in- 
equality of  the  degree  of  paralysis,  especially  in  the  early  period, 
and  in  the  extent  of  its  distribution.  Usuall}'  a  difference  be- 
tween the  two  sides  can  be  detected,  a  certain  movement  of  one 
globe  being  merely  defective,  that  of  the  other  totally  annulled. 
It  is  usual  for  only  some  parts  of  the  oculo-motor  nuclei  to  be 
affected,  most  commonly  those  related  to  the  superior  and  inferior 


DISEASES    OF    THE    BRAIN.  121 

recti.  Occasionally  the  latent  movements  of  the  eye  are  abol- 
ished, or  ptosis  may  be  the  first  and  most  marked  symptom. 
Notlinagel  summarizes  as  follows  :  "  In  a  given  case  in  which  the 
signs  point  to  the  existence  of  a  cerebral  tumor  there  are  grounds 
for  localizing  it  in  the  corpora  quadrigemina  if  the  following 
symptoms  are  present  :  (a)  An  unsteady,  reeling  gait,  especially 
if  this  appears  as  the  first  symptom,  (b)  Associated  with  this 
gait  ophthalmoplegia  existing  in  both  eyes,  but  not  quite  sym- 
metrically nor  implicating  all  the  muscles  in  equal  degree." 

I  have  observed  two  cases  of  ophthalmoplegia  :  the  first  in  a 
very  young  child,  with  double  ptosis  and  paralysis  of  the  internal 
recti ;  there  was  partial  coma  at  the  time  of  my  visit.  She  w^as 
too  young  to  walk,  therefore  the  unsteadiness  of  gait  could  not 
have  been  made  out  if  looked  for  ;  an  autopsy  showed  tumor  of 
the  quadrigeminal  region.  The  second  case,  of  which  a  reproduc- 
tion from  a  photograph  is  given  on  p.  104,  was  three  years  and  a 
half  old.  The  first  symptom  was  double  ptosis,  greatest  on  left 
side  ;  when  first  seen  this  was  the  onl}'  eye  muscle  paralyzed,  and 
the  pupillary  reactions  were  normal ;  there  was  no  staofferinf. 
Later,  the  ptosis  increased,  and  the  internal  rectus  of  right  eye 
was  affected  at  this  stage.  'About  four  months  from  beginning- 
of  ptosis  there  were  occasionally  attacks  of  sudden  dropping  on 
the  floor,  without  loss  of  consciousness,  convulsion,  orparalvsis. 
At  other  times  there  was  sudden  loss  of  consciousness,  as  in 
petit  mat.  Neither  of  these  two  last,  conditions  occurred  more 
than  a  few  times  ;  large  quantities  of  urine  were  passed  which 
contained  sugar  ;  there  were  drowsiness,dullness,  and  irritability  ; 
the  pupils  still  reacted  normally  ;  there  was  no  paralysis  of  the 
extremities.  Later,  the  left  pupil  was  dilated,  but  still  reacted  to 
light  and  accommodation  ;  it  was  only  a  few  weeks  before  death 
that  it  was  fully  dilated  and  ceased  to  react  to  light  and  accom- 
modation. The  right  pupil  remained  normal  in  size  and  re- 
action until  a  week  before  death.  Ten  days  before  death  an  at- 
tack occurred  which,  the  mother  thought,  was  a  convulsion— from 
her  description,  most  likely,  apoplectiform— followed  by  intense 
irritability,  screaming  almost  constantly,  as  if  in  pain— probably 
headache  ;  pupils  ceased  to  react ;  gradually  coma  and  death 
came  on.      All  efforts  to  obtain  an  autopsy   were   fruitless. 


128  NERVOUS    DISEASES    AND    INSANITY. 

The  ptosis  was  never  equally  great  in  the  two  eyes  ;  there  was 
no  staggering  or  reeling.  This  was  quite  evidently  a  tumor  de- 
veloping gradually  in  the  quadrigeminal  region,  slowly  injuring 
the  fibres  of  the  oculo-motor  and  its  nuclei.  The  preservation 
of  the  pupillary  reactions  to  so  late  a  date  in  the  course  of  the 
disease  was  remarkable  ;  this  has  also  been  noted  in  a  case  re- 
ported by  B.  Sachs.  The  inequality  in  the  degree  of  paralysis 
in  the  two  eyes,  which  has  been  pointed  out  by  Nothnagel  as 
characteristic,  existed  in  this  case  to  the  last. 

Lesions  in  the  Crus  Cerebri  give  rise  to  cross  paralysis,  that 
is  hemiplegia  (paralysis  of  the  lower  facial  muscles  and  the  ex- 
tremities on  one  side)  with  paralysis  of  the  oculo-motor  on  the 
same  side  as  the  lesion.  If  the  sensory  tract  is  involved,  there 
would  be  hemiansesthesia  on  the  side  of  paralysis  and  opposite 
the  lesion. 

Lesions  of  the  Pons.  If  the  lesion  is  situated  in  the  upper 
part  of  the  pons,  the  facial  paralysis  is  on  the  same  side  as  the 
paralyzed  extremities.  If  the  lesion  is  unilateral  in  the  lower  part 
of  the  pons,  there  is  marked  facial  paralysis  on  that  side  ;  and 
there  is  motor  and  sensory  paralysis,  licmiplegic  in  type,  on  the 
side  opposite  to  the  lesion. 

This  difference  in  the  condition  of  the  facial  nerve  is  explained 
by  the  decussation  of  the  fibres  in  the  middle  of  the  pons. 

Conjugate  deviaticm  of  the  head  and  eyes  occurs,  as  in  cerebral 
lesions  high  up,  with  this  difierence.  In  cerebral  lesions  high  up, 
with  paralysis  on  the  opposite  side,  the  deviation  is  to  the  side 
of  the  lesion  and  away  from  the  side  of  paralysis.  If  the  lesion 
is  associated  with  convulsions,  the  deviation  is  toward  the  con- 
vulsed members.  If  the  lesion  is  in  the  pons,  the  deviation  is 
toward  the  side  of  paralj^sis  and  away  from  the  side  of  the 
lesion.  If  the  lesion  is  associated  with  convulsions,  the  devia- 
tion is  toward  the  side  of  the  lesion  and  away  from  the  con- 
vulsed members. 

If  the  fifth  nerve  is  involved,  as  it  would  be  in  tumors  develop- 
ing in  the  substance  of  the  pons,  there  would  be  anaesthesia  in 
the  distribution  of  the  nerve,  and  perhaps  painful  sensations. 
In  acute  lesions  of  the  pons  there  are  fever  and  glycosuria. 


DISEASES    OF    THE    BRAIN. 


129 


Lesions  in  the  Cerebellum.  If  situated  in  one  lobe,  and  com- 
paratively stationary,  they  may  give  rise  to  no  locaUzing 
S3'mptoms. 

Fig.  39.  Fig.  40.  Fig.  41. 


Fig.  39.  Common  type  of  hemiplegia  occurring  from  hemorrhage  in  the  neighbor- 
hood of  the  corpus  striatum.  The  shaded  parts  indicate  the  distribution  of  the 
paralysis. 

Fig.  40.  The  type  of  hemiplegia  which  occurs  in  lesions  of  the  cms  cerebri. 
Shaded  portions  indicate  the  paralyzed  parts. 

Fig.  41.  Type  of  hemiplegia  occurring  in  lesions  low  down  in  pons  varolii. 
Shaded  parts  indicate  distribution  of  paralysis. 

The  most  common  manifestations  of  lesions  in  this  portion  of 
the  brain  are  headache,  which  is  usually  occipital,  and  is  often 
9 


130 


NERVOUS    DISEASES    AND    INSANITY. 


pretty  constant.  Tomiting  is  an  early  symptom  ;  it  is  inter- 
mittent, and  has  a  tendency  to  occur  mostly  in  the  mornino-. 
If  the  lesion  is  situated  in  a  lateral  lobe  and  is  slowly  progressive, 
it  soon  gives  rise  to  symptoms.  Lesions  of  the  vermis  give  rise 
to  unsteadiness,  and  a  staggering,  drunken  gait ;  this  is  a  symp- 


FiG.  42. 


To  show  decussation  of  facial  nerve  in  pons  varolii.  (After  Nothnagel.)  1  and 
2.  Eight  and  left  half  of  pons.  3  and  4.  Lesions  at  upper  and  lower  half  of  pons 
on  one  side.  5.  Decussation  at  pyramids  in  medulla.  6.  Fibres  in  pons  which  de- 
cussate in  the  medulla.  7.  Facial  nerve-fibres.  Avhich  are  shown  crossing  in  the 
middle  of  pons. 


tom  which  may  be  very  slight,  and  the  uncertainty  of  gait 
manifested  only  upon  rapid  motions  or  suddenly  turning  round. 
]^ystagmus  in  variety  is  common  ;  it  is  vertical,  horizontal,  or 
oblique.  Lesions  in  the  cerebellum,  as  a  rule,  sooner  or  later 
give  rise  to  additional  symptoms,  which  are  the  result  of  pressure 


DISEASES    OP    THE    BRAIN. 


131 


on  neighboring  parts.  The  long  course  of  the  sixth  nerve  to 
reach  its  ibramen  of  exit  renders  it  very  liable  to  be  pressed 
upon  by  rapidly  increasing  abscess,  cysts,  or  tumors.  Other 
cranial  nerves  may  also  be  compressed  ;  those  injured  will  de- 


FiG,  43. 


Showing  base  of  brain.    The  numbers  on  the  plate  correspond  to  the  nerves. 

pend  upon  the  direction  in  which  the  morbid  product  increases. 
Choked  disc— optic  neuritis,  is  a  frequent  condition  in  lesions  of 
the  cerebellum,  especially  tumor.  There  may  be  some  paresis 
or  paralysis  in  the  extremities  on  one  side.    This  is  evidently  due 


132 


NERVOUS    DISEASES    AND    INSANITY. 


to  pressure  on  surrounding  parts.  Anaesthesia  is  occasionally 
observed.  In  one  of  Seguin's  cases  it  was  located  in  the  dis- 
tribution of  the  fifth  nerve  and  the  tips  of  the  fingers  on  one 
side.  (Contribution  to  the  Pathology  of  the  Cerebellum,  Journal 
Kervous  and  Mental  Disease,  1887.)  I  have  alluded  to  a  few  of 
the  symptoms  of  cerebellar  disease  under  Abscess  of  the  Brain. 

Fig.  44. 


Showing  base  of  skull  with  the  cranial  nerves  as  they  pass  through  their 
loramen  of  exit ;  the  numbering  corresponds  to  the  nerves. 

Lesions  at  the  Base  of  the  Brain.  Lesions  in  the  anterior 
fossa  are  rare ;  disorders  of  smell  would  be  a  guide  to  their 
location.  Paralysis  is  not  caused  by  lesions  in  the  part  of  the 
brain  resting  on  this  portion  of  the  skull,  unless  they  grow  back- 


DISEASES    OF    THE    BRAIN.  133 

ward  so  as  to  compress  the  cranial  nerves  situated  further  back. 
Tlie  most  common  lesions  found  at  the  base  of  the  brain  are 
tumors,  syphilitic  lesions,  and  aneurisms. 

Tumors  in  the  neighborhood  of  the  pituitary  body  cause  com- 
pression of  the  anterior  perforated  space,  optic  tracts,  olfactory 
lobes,  posterior  perforated  space,  corpora  albicantia  ;  and  if  the 
tumor  is  large,  the  pons  and  cerebellum  may  be  pressed  upon, 
or  they  may  encroach  upon  the  nerves  which  pass  through  the 
sphenoidal  fissure  and  the  cavernous  sinus.  If  pressure  is  great, 
there  may  be  paralysis,  but,  as  a  rule,  death  occurs  in  these 
cases  from  paralysis  of  the  respiratory  centre  long  before  pressure 
is  great  enough  to  cause  paralysis.  In  a  case  of  cystic  tumor  of 
the  pituitary  body,  coming  under  my  observation,  there  were 
headache  not  specially  located  ;  vomiting  which  occurred  occa- 
sionally ;  attacks  of  sudden  falling  without  loss  of  conscious- 
ness or  convulsion,  from  which  there  was  recovery  at  once  ;  a 
passing  paralysis  of  the  right  sixth  nerve  toward  the  end  of  the 
disease.  In  my  examination  two  months  before  death  there 
was  choked  disc.  Death  occurred  very  suddenly  upon  getting 
out  of  bed  to  use  a  commode.  There  may  be  glycosuria  in  these 
cases.  Tumors  anywhere  in  the  neighborhood  of  the  fourth 
ventricle,  so  as  to  cause  irritation,  may  give  rise  to  this  symptom. 
A  diagnosis  is  made  of  the  location  of  lesions  at  the  base  of  the 
brain  by  noting  the  nerves  involved  and  their  order  of  implica- 
tion, in  conjunction  with  the  other  symptoms.  A  reference  to 
the  illustrations  of  the  base  of  brain  and  skull  will  make  this 
clear. 

Bibliography.— Am'idon,  Kew  York  Medical  Journal,  1885. — 
Bernard,  De  PAphasie,  1885.— Seguin,  Journal  Xervous  and 
Mental  Diseases,  1886-1890.— Koss,  Aphasia,  1887. — Lichthenim, 
Brain,  1887. — Mills,  Transactions  Congress  American  Physicians 
and  Surgeons,  held  at  New  Haven,  1888.— Starr,  Cortical 
Lesions,  American  Journal  Medical  Sciences,  1889. — Starr, 
Sensory  Aphasia,  Brain,  1889. — Dana,  Journal  ISTervous  and 
Mental  Diseases,  1889. — Ferrier,  Functions  of  the  Brain, 
1886. — Ferrier,  Localization  of  Cerebral  Disease,  1878.  — Ferrier, 
Croonian  Lectures  on  Cerebral  Localization,  1890. 


134  NERVOUS    DISEASES    AND    INSANITY. 


SECTION  IV. 
Chorea, 

Etiology.  Heredity  plays  an  important  part  in  its  produc- 
tion ;  it  affects  chiefly  children,  girls  more  frequently  than  boys  : 
it  may  be  due  to  anything  which  tends  to  lower  the  general 
vitality.  There  appears  to  exist  a  relationship  between  chorea 
and  rheumatism.  Fright,  anxiety,  over-strain  at  school,  with 
confinement,  are  exciting  causes  in  those  predisposed. 

Symptoms.  The  child  becomes  listless,  inattentive,  neglects 
its  school  work  ;  intellect  is  dulled  ;  poor  appetite— soon  fol- 
lowed by  irregular  muscular  twitchings  in  the  face  or  one 
arm,  or  may  be  confined  to  one  arm  and  one  leg.  Occasion- 
ally there  is  paresis  of  one  side  as  the  first  symptom  ;  the 
muscular  twitchings  cause  constant  facial  distortions  ;  the  arm 
is  jerked  from  side  to  side  in  paroxysms;  the  child  holds  the 
affected  hand  with  the  sound  one  to  prevent  these  movements. 
The  choreic  twitchings  may  be  general,  and  it  is  almost  impos- 
sible for  the  child  to  use  its  limbs ;  it  stumbles  and  falls  in  all 
directions.  I  have  seen  one  case  in  which  all  extremities,  head, 
eyes,  and  muscles  of  the  throat  were  affected  ;  it  was  almost 
impossible  for  the  child  to  speak  and  swallow. 

While  these  muscles  were  twitching  at  intervals,  throwing 
the  parts  into  undesired  positions,  they  were  paretic  ;  the  arms 
and  legs  could  not  be  moved  voluntarily,  and  the  head  dropped 
in  any  direction  if  unsupported.  Besides  the  pains  in  the  limbs 
which  some  children  complain  of,  there  are  no  sensory  synip- 
toms.  The  little  sufferers  are  always  irritable,  depressed,  and 
emotional,  and  mentally  inactive  ;  if  kept  at  school  they  can- 
not learn  and  take  no  interest  in  their  studies.  There  is  an  en- 
docardial murmur  in  some  cases  ;  the  pulse  may  be  irregular 
and  weak.  There  may  be  several  attacks,  with  intervals  of  a 
few  months  or  years. 


HEREDITARY    CHOREA.  135 

Pathological  Anatomy.  There  arc  no  distinctive  lesions  in 
chorea.  Dana  has  attempted  to  sum  up  what  is  known  of  the 
changes  (Brain,  1890).  These  consist  of  subcortical  and  basal 
hyperaemia,  paralyzed,  dilated,  and  badly  nourished  arteries, 
exudations  in  the  lymph  spaces,  and  similar  changes  which 
are  evidently  secondary. 

Prognosis  and  Duration.  The  prognosis  is  favorable  in  almost 
all  these  cases,  especially  the  acute  ;  the  duration  under  treat- 
ment is  usually  from  four  to  eight  weeks. 

Treatment.  This  should  consist  in  removal  of  any  cause  which 
can  be  discovered.  The  bowels  and  digestion  should  be  regu- 
lated ;  ample  light  nutritious  diet,  with  cold  sponging  night  and 
morning  ;  abundance  of  fresh  air,  avoidance  of  close  rooms  ;  the 
bed-rooms  should  be  well  ventilated,  especially  at  night,  keep- 
ing the  children  out  of  doors  as  much  as  possible.  Absolute 
rest  in  bed  has  been  advised,  and  may  be  suitable  for  those 
cases  where  there  are  excessively  disordered  movements  or 
paresis  associated  with  them.  In  other  cases  I  prefer  keeping 
the  children  out  of  doors,  and  allowing  them  to  play  about. 
If  there  is  much  pain,  or  a  slightly  elevated  temperature,  a  few 
doses  of  antipyrine  may  be  given,  provided  there  is  no  serious 
heart  lesion.  If  the  child  is  in  very  poor  physical  condition 
cod-liver  oil  may  be  given.  Of  the  medicinal  treatment.  Fow- 
ler's solution  is  one  of  the  best,  or  pyrophosphate  of  iron. 

Hereditary  Chorea. 

This  is  a  condition  which  was  first  mentioned  by  Dr.  Water>:, 
of  Franklin,  IST.  Y.,  in  a  letter  to  Dunglison  in  1842.  It  was  a 
form  of  chorea  found  in  certain  families  in  his  neighborhood  ;  it 
was  hereditary  ;  rarely  appeared  before  adult  life  ;  was  incurable, 
and  dementia  always  followed.  Twenty  years  later,  Lyon  wrote 
about  it  (American  Medical  Times,  1863) ;  he  gave  three  histories 
in  which  five  and  three  generations  were  affected. 

In  1872  Huntingdon  described  it  in  a  few  cases  on  Long 
Island.  He  says  that  it  affects  males  more  frequently  than 
females  ;  and  comes  on  gradually,  always  after  middle  life,  and 
is  incurable  ;  it  always  ends  in  insanity,  and  there  is  a  tendency 


136  NERVOUS    DISEASES    AND    INSANITY. 

to  suicide.  (Phil.  Medical  and  Surgical  Reporter,  1872.)  Clar- 
ence King,  in  1885,  gives  the  family  history  of  the  disease.  It  is 
hereditary,  and  affects  a  great  many  members  of  a  family,  and 
for  several  generations  ;  it  affects  both  sexes,  and  begins  usually 
after  twenty-fiv^e  years  of  age  ;  it  may  be  transmitted  through 
the  paternal  or  maternal  side.  It  does  not  develop  from,  ordinary 
chorea,  and  begins  without  apparent  cause  by  a  twitching  of  the 
face,  then  the  arms  are  affected,  and  later  the  legs,  or  it  may 
begin  as  a  general  twitching.  The  movements  may  be  violent 
and  coarse  in  character  ;  in  the  leg  it  produces  a  peculiar  gait ; 
there  is  sudden  stopping  ;  the  persons  look  as  if  they  were  going 
to  fall  forward,  the  body  sways  ;  at  last  they  are  able  to  take  a 
few  rapid  steps,  and  so  recover  their  balance.  In  most  cases 
the  movements  cease  in  sleep.  There  is  no  wasting  of  the 
muscles,  no  anaesthesia,  the  deep  reflexes  are  normal  or  some- 
what increased  ;  the  electrical  reactions  are  normal.  There  is 
no  heart  disease  ;  rheumatism  is  not  associated  with  it,  as  in 
ordinary  chorea.  The  bodily  functions  are  normal.  It  is  very 
commonly  followed  by  some  mental  disorder.  The  choreic  in- 
sanity begins  with  loss  of  memory  and  childishness,  gradually 
passing  into  dementia. 

The  Pathological  Anatomy  is  not  known.  A  few  autopsies 
have  shown  subdural  hemorrhage  ;  one,  multiple  tumors  of  the 
dura  mater. 

Bibliography, — Sinkler,  Pepper's  System  of  Medicine. — Her- 
ringhara.  Brain,  1888.  — Sinkler,  Journal  Nervous  and  Mental 
Disease,  1888. 

Neurasthenia. 

(A  Condition  of  E2:haustion  of  the  Nervous  System.) 

Etiology.  A  predisposition  to  it  may  be  inherited  or  be 
acquired.  The  nervous,  highly  active,  restless  temperament 
is  most  subject  to  it.  It  usually  occurs  at  a  time  of  life 
when  the  anxieties  and  work  inseparable  from  our  mode  of 
existence  are  in  full  operation.  It  is  brought  on  frequently  in 
men  by  too  prolonged  and  anxious  work,  and  excesses  of  all 


NEURASTIIENrA.  137 

kinds,  which  lower  the  vitality.  In  women,  by  cares  and  petty 
annoyances,  with  an  enervating  mode  of  life  ;  too  rapid  preg- 
nancies, tlie  drain  from  lactation,  profuse  discliarges  of  blood. 
Exhausting  diseases  of  all  kinds  may  bring  it  on. 

Symptoms.     It  exhibits  the  most  wonderful  variation  in  its 
symptoms,  and  yet  there  is  a  similarity  about  them  which  makes 
the  disease  distinct  and  easily  recognizable,  at  least  in  its  typical 
manifestations.     A  number  of  divisions  have  been  made,  such 
as  cerebral,  spinal,  sexual  neurasthenia  ;  but  tliese  are  purely 
arbitrary,  and  simply  have  for  their  basis  a  preponderance  of 
symptoms  referable  to  the  brain,  spine,  and  sexual  apparatus, 
etc.,  but,  after  all,  the  condition  is  general.      The  symptoms 
most  commonly  met  with  are  inability  for  exertion  ;  the  person 
is  easily  tired,  has  no  ability  to  do  mental  work  ;  he  is  c(mfused, 
gets  headache  on  the  least  effort,  has  vague  pains  about  the 
head,  and  neuralgic-like  pains  about  the  body,  with  sensafons 
of  prickling  and  numbness.     The  head  and  neck  tire  easily  and 
ache  ;  tender  painful  spots  may  be  felt  at  one  or  more  points  along 
the  spine  ;  sleeplessness  is  common.     The  sufferers  are  appren- 
hensive  and  anxious  unnecessarily  ;  dread  they  will  have  some 
serious  disease.     On  the  least  exertion  they  have  palpitation  ; 
perspiration  breaks  out  on  them,  and  they  have  Hushing  of  the 
face  ;  there  may  be  palpitation  which  occurs  at  night  and  wakes 
them,  causing  them  great  distress  and  anxiety.     They  dislike 
to  make  mental  and    physical  effort.     Dyspepsia  often  comes 
on,  either   as   a    complication,    or  was   the   original   difficulty. 
When  they  take  food  they  are  distressed  and  uncomfortable ;  the 
head  symptoms  are  made  worse.     They  are  confused  and  dizzy  ; 
palpitation  may  occur  ;  they  gradually  leave  out  of  their  diet 
first  one  and  then  another  article,  until  they  have  got  themselves 
down  to  a  starvation  point,  making  their  condition  rather  worse 
than  better.    Their  attention  becomes  concentrated  upon  them- 
selves and  their  organs.    Many  of  them  become  hypochondriacal 
often  about  their  sexual  apparatus,  and  they  consult  one  physi- 
cian after  another.     A  feeling  of  constriction  about  the  head, 
with  discomfort  and  pain  on  the  top  of  the  head,  is  very  com- 
mon.    These  persons  are  usually  pale  and  anaemic,  with  appe- 
tite poor,  bowels  constipated,  spirits  depressed,  and  facial  ex- 


138  NERVOUS    DISEASES    AND    INSANITY. 

pression  often  anxious.  They  avoid  strangers,  and  may  develop 
morbid  fears  of  all  kinds.  They  remain  in  the  house,  on  the  plea 
that  going  out  makes  them  uncomfortable,  increases  the  pains 
in  the  back  and  head,  tires  them  ;  or  they  dread  that  something 
will  happen  to  them,  that  they  will  faint,  or  have  an  attack  of 
paralysis,  etc. 

Prognosis  in  these  cases  is  always  ftivorable ;  all  these  patients 
will  get  well  under  suitable  treatment. 

Treatment.  Remove  the  causes  which  have  operated  to  bring 
about  the  condition  ;  avoid  over-work,  and,  above  all,  anxiety, 
if  that  be  possible  ;  stop  any  drains  wdiich  are  being  made  on 
the  system,  such  as  hemorrhages,  lactation,  etc.  A  good  ample 
supply  of  food  is  most  important,  with  fat  of  some  kind  in  the 
winter  ;  cod-liver  oil  or  cream  can  be  used.  Medicinally,  tinct. 
nux  vomica  may  be  taken  before  meals,  with  pepsin  after  meals, 
and  if  there  is  much  gas  formed  in  the  stomach  and  intestines, 
charcoal  may  be  added.  The  bowels  should  be  kept  regular,  if 
they  do  not  act  when  the  full  meal  is  taken,  with  nux  vomica, 
cascara  sagrada,  or  the  small  granules  of  aloin,  belladonna  and 
strychnia  can  be  given  at  night.  If  there  is  m.uch  anaemia,  later, 
quinia  and  iron  or  arsenic  can  be  given.  The  person  should  live 
out  of  doors,  if  the  weather  admits,  and  if  possible  remove  to 
some  new  locality,  temporarily,  with  cheerful  surroundings.  He 
should  be  encouraged  to  take  moderate  exercise  at  first,  gradu- 
ally increasing  it,  but  never  to  excess.  Cold  sponging  in  the 
morning  is  of  service  in  a  large  number  of  cases.  Stimulants 
should  be  avoided.  This  line  of  treatment  should  be  continued 
for  a  long  time. 

Bihliogi'apliy . — Beard,  Nervous  Exhaustion. — Cowles,  Boston 
Med.  and  Surg.  Journal,  1891. 

Headache,  Cephalalgia. 

Headache,  the  result  of  organic  brain  disease,  such  as  tumor, 
is  not  included  under  this  head. 

Any  cause  which  lowers  the  general  tone  may  give  rise  to  it — 
such  as  anismia  from  any  source,  the  presence  in  the  blood  of 


HEADACHE,    CEPHALALGIA.  189 

material  foreign  to  it,  or  the  permeation  of  the  organism  by  j)oi- 
sonous  substances — tobacco,  lead,  products  of  defective  assimi- 
lation, etc.  It  may  be  the  result  of  irritations  and  disturbances 
in  other  parts  of  the  organism — such  as  disorders  of  the  stomach, 
constipation,  disease  of  the  teeth,  nose,  throat,  or  eye  ;  or  it  may 
occur  from  sleeping  in  badly-ventilated  rooms,  from  the  inhala- 
tion of  deleterious  gases.  It  also  occurs  in  gout,  in  rheuma- 
tism, and  in  neurasthenic  individuals.  It  varies  very  much  in  its 
severity  ;  it  may  be  constant  or  intermittent,  general  or  local- 
ized. An  attempt  has  been  made  to  classify  these  headaches 
according  to  their  cause,  and  it  is  believed  that  certain  sources 
of  irritation  give  rise  to  a  headache  localized  in  a  special  part 
of  the  head  ;  for  instance,  the  headache  of  indigestion  and  con- 
stipation is  frontal,  while  the  headache  of  anaemia  is  on  the  top 
of  the  head.  The  location  of  the  headache  is  not  always  a  guide 
to  its  etiology. 

Anaemic  headache  occurs  mostly  in  women  ;  it  may  be  diffuse, 
on  the  top  of  the  head,  or  the  temples  ;  it  is  found  in  pale  and 
bloodless  persons  ;  it  is  often  associated  with  fainting  attacks  ; 
it  is  made  worse  by  want  of  nourishment,  rest,  and  sleep  ;  over- 
work and  anxiety  increase  it. 

Congestive  headache  is  found  mostly  in  men,  and  is  associated 
with  full  blood,  congested  face,  throbbing  arteries,  and  vertigo, 
with  a  feeling  of  fulness  in  head. 

Hysterical  and  neurasthenic  headache  are  very  much  alike, 
and  are  often  located  on  the  top  of  the  head,  or  on  one  side,  de- 
scribed as  boring  ;  made  worse  by  worry  and  menstruation. 

Toxic  headaches  are  usually  general,  but  they  may  be  frontal ; 
tobacco,  opium,  iron,  and  other  drugs  may  cause  it.  Seguin  has 
pointed  out  that  the  headache  of  uraemia  is  often  occipital. 

Syphilitic  headache  is  often  very  severe,  and  may  be  general 
or  localized  ;  is  apt  to  be  worse  at  night ;  is  usually  constant. 

It  occurs  in  young  children  who  are  of  a  nervous  temperament 
and  use  their  eyes  too  constantly,  or  tax  their  brain  beyond  its 
endurance  and  powers,  and  who  are  worried  and  anxious  about 
their  work.  Sinkler  says  it  may  be  associated  with  enlarged 
tonsils. 

The  treatment  of  headache  must  depend  upon  its  cause  ;  this 


140  NERVOUS    DISEASES    AND    INSANITY. 

must  be  sought  after.  In  the  anaemic  headaches,  tonics,  arsenic, 
iron  combined  with  a  saline,  if  the  person  will  tolerate  it  ;  nu- 
tritious food,  some  wine  ;  cold  bathing  with  friction.  The 
digestion  should  be  strengthened  with  some  stomachic  bitters, 
or  pepsin  may  be  given  after  meals  ;  the  bowels  should  be  kept 
regular.  In  the  syphilitic  headache,  iodide  of  potassa.  In  the 
hysterical  and  neurasthenic  headaches  the  treatment  indicated 
for  the  anaemic  form,  for  the  relief  of  a  paroxysm,  1  to  3  grains 
of  citrate  of  caffein  will  be  of  service.  In  toxic  headaches  the 
cause  must  be  removed.  In  nervous,  highly  neuropathic  chil- 
dren, avoidance  of  over-work  and  anxiety,  plenty  of  fresh  air  out 
of  doors,  plenty  of  light  nutritious  food,  cold  bathing.  In  those 
cases  which  appear  to  depend  upon  strain  of  the  eyes,  if  there  is 
refractive  trouble  it  should  be  corrected,  but  this  alone,  in  my 
experience,  does  not  always  cure  the  headache,  but  for  the  time 
relieves  it ;  there  is  a  neurotic  condition,  the  basis  of  the  ceph- 
alalgia ;  all  sources  of  peripheral  irritation  should  be  sought  for 
and  corrected. 

Exophthalmic  Goitre. 

(Graves's  Disease.) 

Etiology.  This  disease  occurs  almost  exclusively  in  women. 
Heredity  plays  a  prominent  part  as  a  predisposing  cause.  Dis- 
turbances in  nutrition,  anaemia,  chlorosis,  drains  upon  the  system 
by  profuse  discharges  of  blood,  illnesses  which  lower  the  vitality, 
are  exciting  causes  of  its  outbreak.  Mental  anxiety  and  disap- 
pointments are  fruitful  sources  of  it  in  predisposed  persons. 

Symptoms.  It  begins  with  palpitation,  rapid  pulse,  which 
may  reach,  eventually,  120  or  150  beats  per  minute  ;  it  may 
begin  gradually,  or  the  symptoms  may  be  ushered  in  sud- 
denly, as  the  result  of  fright  or  other  profound  emotional  dis- 
turbance. Enlargement  of  the  thyroid  gland  occurs  as  a  very 
constant  accompaniment  ;  the  degree  of  enlargement  varies 
very  much  ;  vomiting  occasionally  occurs,  with  dyspeptic  symp- 
toms, and  there  may  be  a  disposition  to  vomit  when  certain 
kinds  of  food  are  taken.  The  appearance  of  these  symptoms 
varies.     In  some  cases  there  is  a  light  swelling  of  the  thyroid 


EXOPHTHALMIC    GOITRE.  141 

gljind  ill  itB  entirety  or  in  one  lobe  for  a  number  of  months 
before  the  palpitation  occurs  ;  in  others  the  palpitation  is  the 
first  to  appear. 

Exophthahnus,  more  or  less  extensive,  soon  appears  ;  it  may 
be  so  great  that  the  lids  cannot  be  closed  over  the  eyeballs.  Yon 
Graefe  pointed  out  that  the  upper  lid  loses  its  power  of  moving 
in  harmony  with  the  movements  of  the  eyeball.  In  some  ex- 
treme cases  ulcerations  of  the  cornea  may  occur  and  the  sight  be 
lost  in  consequence.  Slight  elevation  of  the  temperature  may 
occur.  The  person  is  excessively  nervous,  easily  agitated,  and 
frightened. 

Pathological  Anatomy.  Changes  have  been  found  in  the  thy- 
roid gland,  and  in  the  cervical  sympathetic  and  its  ganglia, 
while  some  observers  have  not  found  them  in  these  bodies. 
These  changes  are  not  constant,  and  there  is  nothing  definite 
known  of  the  pathological  anatomy  of  this  disease. 

Diagnosis.  When  the  symptoms  are  well  developed,  it  pre- 
sents no  difiiculty. 

Prognosis.  Is  unfavorable  as  a  rule.  Some  of  the  cases  im- 
prove, but  there  is  great  danger  of  relapses. 

Treatment.  Is  unsatisfactory.  Digitalis  and  other  remedies 
for  slowing  the  heart's  action  have  been  given  with  very  little 
result.  If  nutrition  is  impaired,  tonics,  quinia,  arsenic,  and 
iron,  with  nourishing  diet,  change  of  scene,  cold  sponging,  gal- 
vanism, and  removal  of  any  source  of  anxiety  which  it  is  pos- 
sible to  relieve,  are  needed.     Faradism  has  been  advocated. 

Angina  Pectoris. 

Etiology.  It  may  be  a  symptom  of  organic  disease,  fatty  de- 
generation of  the  heart,  or  disease  of  the  coronary  arteries. 

The  neurosis  is  an  obscure  affection  and  appears  to  have  an 
hereditary  basis  ;  it  is  found  in  families,  the  members  of  which 
are  subject  to  hysteria,  epilepsy,  or  other  nervous  disorders.  It 
may  be  an  hysterical  symptom  ;  such  a  case  has  fallen  under 
my  observation.  Males  are  said  to  be  the  more  frequently 
affected.     Excessive  use  of  tobacco  may  cause  it. 

Symptoms.    It  comes  on  suddenly  in  paroxysms  of  variable 


142  NERVOUS    DISEASES    AND    INSANITY. 

duration.  It  begins  by  pain  in  pericardial  region,  extending  to 
side  of  neck,  and  down  left  arm  ;  there  is  intense  difficult}"  in 
breathing,  oppression  associated  with  pain  of  a  shooting,  tear- 
ing character.  The  person  is  in  great  distress  and  anxiety,  face 
pale,  cold  perspiration  over  the  body.  The  pulse  may  become 
feeble  and  intermittent.  The  attack  lasts  usually  a  very  short 
time.  The  arterial  tension  is  increased  at  the  beginning  of  the 
attack,  later  it  is  diminished. 

Diagnosis.  Examination  must  be  made  to  learn  if  the  symp- 
toms depend  upon  some  diseased  condition  of  the  heart,  or  upon 
a  simple  neurosis. 

Prognosis.    Is  always  serious. 

Treatment.  If  due  to  tobacco,  its  use  should  be  avoided.  If 
dependent  upon  cardiac  disease,  the  treatment  appropriate  for 
that  condition  should  be  adopted.  In  the  condition  of  nervous 
origin,  ether,  chloroform,  hypodermics  of  morphia  may  be  used. 
In  the  form  with  vascular  spasm,  inhalations  of  amyl  nitrite 
often  give  prompt  relief.  Between  the  paroxsyms  tonics,  qui- 
nine, arsenic,  should  be  given.     Galvanism  has  been  used. 

Unilateral  Facial  Atrophy 

Is,  as  its  name  implies,  a  gradual  wasting  of  the  muscular  tissue 
on  one  side  of  the  face. 

Etiology.  It  is  more  frequent  in  vromen  than  in  men  ;  it  occurs 
usually  at  a  comparatively  early  age,  under  thirty,  and  in  a  few 
cases  recorded  between  ten  and  fifteen  years  of  age.  It  appears 
to  occur  more  frequently  on  the  left  side  of  the  face. 

It  has  followed  the  eruptive  fevers,  pertussis,  and  other  dis- 
eases. In  a  few  cases  there  has  been  pain  in  the  superior  max- 
illary region  ;  its  etiology  is  not  clear. 

Symptoms.  It  begins  as  a  discoloration  on  the  side  of  the 
face  in  spots,  which  spread  ;  these  spots  become  3'ellowish  and 
depressed  ;  the  face  gradually  grows  thinner  on  that  side  as  the 
tissue  gradually  wastes  ;  the  hair  undergoes  changes  as  well 
as  the  skin,  and  may  become  perfectly  wdiite.  The  cutaneous 
sensibility  is  usually  not  affected  ;  the  skin  becomes  drawn, 
wrinkled,  and  hard,  but  it  is  not  adherent  to  the  bone.     The 


HYSTERIA.  14B 

electrical  reactions  are,  as  a  rule,  said  to  be  normal.  The  degree 
of  atrophy  varies  very  much.  The  bones  have  been  found 
diminished  in  size.  In  a  case  which  I  have  had  the  opportunity 
of  seeing,  through  the  kindness  of  Dr.  S.  Shervvell,  the  atrophy 
was  extreme,  and  both  sides  of  the  face  were  affected  ;  the 
woman,  although  young,  looked  as  if  she  were  very  old  ;  there 
was  no  anaesthesia. 

Pathology.  Two  theories  are  offered  in  explanation  of  this 
condition  :  one  is  that  it  depends  upon  a  disorder  of  the  vaso- 
motor system  ;  the  other,  upon  a  disorder  in  the  trophic  fibres 
of  the  fifth  nerve.  It  is  difficult  at  present  to  sa}'  to  which  of  these 
two  theories  the  greater  weight  should  be  given.  The  disease  may 
depend  upon  a  disturbance  in  both,  as  the  fifth  nerve  and  sym- 
pathetic are  so  intimately  associated.  Cases  have  been  recorded 
in  which  injury  to  the  sympathetic  has  appeared  to  cause  it. 

Diagnosis.  It  may  be  mistaken  for  an  asymmetrical  face, 
but  in  this  condition  there  is  absence  of  the  discoloration  and 
atrophy. 

Prognosis.    It  is  not  dangerous  to  life. 

Treatment.     Very  little  can  be  said  on  this  subject. 

Hysteria 

Is  a  morbid  state  of  the  nervous  system  in  which  the  clinical 
manifestations  present  the  most  wonderful  variety,  and  in  a 
remarkable  manner  simulate  organic  disease  ;  there  is  ofteu 
increased  physical  irritability.  It  is  often  manifested  by 
neuralgic-like  pains,  hypersesthesias,  hallucinations,  convulsive 
and  paralytic  phenomena. 

Many  years  ago  hysteria  was  supposed  always  to  be  the  result 
of  disease  of  the  uterine  appendages,  and,  consequently,  a  disease 
confined  entirely  to  women  ;  but  it  is  now  known,  thanks  to  the 
labors  of  Prof.  Charcot  and  his  pupils,  Seguin,  Walton,  J.  J.  Put- 
nam, Page,  and  many  others,  that  it  occurs  frequently  in  men 
and  young  children.  The  name  hysteria  is  used  in  a  sense  very 
different  from  that  in  which  it  was  formerly  used,  and  does  not 
indicate,  in  the  least,  that  the  condition  depends  upon  abnor- 
mal states  of  the  uterus.     This  it  is  important  to  keep  in  mind. 


14:1:  NERVOUS    DISEASES    AND    INSANITY. 

Etiology.  Heredity  plays  a  most  important  part  in  its  pro- 
duction. There  may  be  a  direct  transmission  of  h3-steria  from 
the  parent  to  the  child,  or  there  may  be  other  nervous  mani_ 
fcslations  in  the  members  of  the  family  and  its  branches,  such 
as  epilepsy,  chorea,  neuralgia,  insanity  in  some  of  its  phases,  or 
some  other  nervous  disorder.  It  occurs  more  frequentl}^  in 
women,  but  it  is  much  more  common  in  men  than  is  ordinarily 
believed  ;  it  occurs  in  boys  and  girls  at  a  tender  age,  or  about 
the  time  of  puberty.  Briquet  found  that  one-eighth  of  his  cases 
were  in  children  under  ten  years  of  age.  Anything  which 
lowers  the  general  tone  of  the  nervous  system  may  give  rise  to 
it  in  these  over-sensitive,  predisposed  persons.  Hemorrhages, 
severe  illness,  poor  food,  ansemia,  over-work  in  occupations 
which  are  not  congenial,  anxiety,  fright,  jealousy,  disappoint- 
ments of  all  kinds,  make  a  profound  impression ;  so  does  an 
education  which  fosters  and  stimulates  this  inherited  instability. 
The  enforced  social  restrictions  of  women,  which  they  often  in- 
flict upon  their  young  children,  with  lack  of  proper  exercise  for 
pliysical  development,  and  an  artificial  and  premature  educa- 
tion and  habits  heighten  this  predisposition.  But  it  occurs  in 
persons,  men  particularly,  of  robust  physique,  who,  up  to  the 
time  of  the  first  hysterical  manifestation,  have  not  exhibited 
the  least  morbid  emotional  susceptibility.  Accidents  are  a 
frequent  cause  of  the  first  appearance  of  the  condition,  as  has 
been  clearly  pointed  out  by  Charcot ;  and  several  well-marked 
cases  of  the  kind  have  fallen  under  my  observation.  Putnam 
and  Walton  have  also  recorded  a  number  of  such  cases.  The 
disease  may,  at  times,  occur  in  young  girls  who  have  witnessed 
attacks  in  others. 

Symptoms.  Plysterical  persons  often  complain  of  some  of  the 
symptoms  found  in  neurasthenia,  neuralgic-like  pains  in  vari- 
ous parts  of  thebody,  and  hyperaesthetic  areas  about  theabdomen, 
chest  or  back.  A  frequent  location  of  them  is  in  the  neighborhood 
of  the  ovary,  mammary  gland,  etc.  There  may  be  anaesthetic 
patches  in  various  parts  of  the  body,  or  there  may  be  complete 
hemiantesthesia,  which  is  associated  with  anaesthesia  of  the 
mucous  membranes.  The  special  senses  on  that  side  are  in- 
volved, sight,  taste,  and  hearing.     There  may  be  restriction  of 


HYSTERIA.  145 

the  visual  field  for  color.     The  degree  and  completeness  with 
which  these  manifestations  present  themselves  vary. 

There  may  be  irritations  of  the  bladder  and  urethra.  Patients 
often  complain  of  pain  in  the  joints,  which  may  be  mistaken  for 
joint  disease,  especially  if  there  happen  to  be  some  swelling. 
Sir  Benjamin  Brodie  called  attention  to  the  frequency  of  these 
hysterical  joint  troubles  ;  and  more  recently,  in  this  country, 
!Rewton  Sliatier  has  made  a  valuable  contribution  on  the  sub- 
ject. In  some  cases  of  hysteria  the  senses  are  exceedingly 
acute.  Persons  notice  odors  which  are  not  perceptible  to 
others  ;  they  are  often  made  very  sick  by  odors  which  have  no 
influence  on  normal  individuals.  On  the  other  hand,  they  may 
have  a  liking  for  odors  and  substances  disagreeable  to  other 
persons  ;  these  perverted  senses  are  well  shown  in  an  abnormal 
taste,  in  eating  soap,  slate  pencils,  small  chalky  or  soft  stones, 
etc.  The  hysterical  manifestations  in  some  are  simply  an  ex- 
aggeration of  their  emotional  state  ;  they  laugh  and  cry  with- 
out cause.  Where  there  is  a  more  or  less  profound  attack, 
there  are  likely  to  be  present  a  number  of  hysterical  manifes- 
tations. In  the  anaesthesia  which  occurs  in  these  cases,  as  a 
rule,  the  sensibility  to  pain  is  alone  overcome  ;  the  other  forms 
of  sensibility  are  normal ;  occasionally  tactile  sensibility  is  dis- 
turbed, and  the  muscular  sense  may  in  some  cases  be  abolished. 
The  anaesthesia  may  affect  the  mucous  membranes  of  mouth, 
pharynx,  and  nose;  and  in  consequence  the  reflexes  of  the  parts 
art?  abolished.  The  secretions  ma}^  be  diminished  or  arrested. 
Spasmodic  convulsions  and  paralytic  phenomena  may  occur. 
The  spasmodic  attack  may  be  of  great  variety:  it  may  be  rhyth- 
mical ;  it  may  simulate  the  trembling  of  organic  disease  ;  be 
con  lined  to  one  member  or  involve  the  entire  half  of  the  body 
and  be  hemiplegic  in  type  ;  it  may  be  coarse,  as  in  disseminated 
sclerosis  ;  or  fine  tremor,  as  in  paralysis  agitans  ;  or  may  simu- 
late the  pre-  and  post-hemiplegic  trembling  of  organic  disease  ; 
it  may  occur  in  any  muscle  or  group  of  muscles  in  the  body  ;  it 
may  manifest  itself  as  contracture,  which  may  be  intermittent 
or  last  continuously  for  months  and  years.  Prof.  Charcot  has 
pointed  out  the  permanency  of  these  conditions  and  the  ob- 
stinacy to  treatment  which  often  characterize  them.  These 
10 


146  NERVOUS    DISEASES    AND    INSANITY. 

contractures  may  be  coufined  to  the  masseter  and  other  muscles 
in  their  neighborhood,  causing  trismus.  Many  years  ago  I  pub- 
lished the  record  of  a  very  obstinate  case  of  this  kind  (Hysteri- 
cal Trismus,  Transactions  of  the  American  Neurological  Asso- 
ciation, 1887,  vol.  2),  which  lasted  for  months.  Spasms  of  the 
glottis  may  take  place,  giving  rise  to  severe  dyspnoea  ;  or  of  the 
pharynx,  causing  difficulty  in  swallowing.  Globus  hystericus 
is  rather  a  constant  symptom,  but  not  so  frequent  as  it  is  often 
thought  to  be.  Persistent  and  severe  vomiting  often  occurs ; 
but  the  nutrition  rarely  suffers  materially  from  these  attacks. 
Retention  of  urine  is  frequent,  owing  to  spasm  of  the  sphincter  ; 
and  the  catheter  may  have  to  be  used  for  months. 

Paralysis  occurs  in  these  cases  ;  it  is  variable  in  distribution, 
and  may  come  on  suddenly  after  a  convulsive  attack  or  without 
it ;  it  may  be  flaccid  or  associated  with  contracture ;  it  may 
come  on  slowly ;  it  may  be  confined  to  one  limb  or  be  hemi- 
plegic  in  type.  Some  years  ago  I  was  consulted  by  a  lady 
whose  domestic  relations  were  not  agreeable.  After  an  un- 
pleasant occurrence  in  her  home  she  was  suddenly  seized  with 
contracture  of  the  right  leg  and  partial  trismus,  which  had 
lasted  many  months  without  abatement  when  I  saw  her. 
These  paralytic  phenomena  may  disappear  in  a  short  time  to 
occur  again  in  the  same  parts  or  in  some  other  parts,  after  the 
lapse  of  a  few  months.  I  have  recently  observed  these  mani- 
festations in  a  young  girl.  There  may  be  no  ansesthesia  in 
these  cases.  This  young  woman,  in  addition  to  the  paralysis, 
had  only  a  darkening  in  the  centre  of  the  visual  field.  Objects 
appeared  to  be  in  the  shadow  as  the  centre  of  the  field  was 
approached  ;  in  the  centre  of  the  field  they  were  dark,  as  if 
observed  in  the  night.  The  color  perception  was  not  changed, 
and  there  was  no  anaesthesia. 

These  persons  are  impressionable  ;  easily  affected  by  pleasur- 
able or  painful  impressions ;  and  there  is  often  a  morbid  craving 
for  sympathy  and  attention.  This  morbid  state  may  present 
itself  in  persons  who  had  previously  not  shown  the  least  sign  of 
nervous  impressionability.  They  may  show  a  tendency  to  moral 
perversions  :  lie,  steal,  quarrel  with  and  intrigue  against  their 
own  family.     They  often  form  attachments  and  dislikes  to  per- 


HYSTERIA.  147 

sons  without  obvious  reason,  and  as  frequently  change  them. 
They  often  manifest  an  aversion  to  certain  creatures,  such  as 
frogs,  spiders,  mice,  cats,  etc.  Others  show  a  desire  to  deceive, 
often  for  deception's  sake  ;  or  to  make  tliemselves  the  objects  of 
curiosity  and  wonder.  To  this  end  they  drink  urine  and  eat 
excrement,  whicli  they  vomit  up,  or  they  pretend  that  urine 
passes  through  the  navel  or  other  part  of  the  body  ;  or  they 
may  inflict  injuries  upon  themselves,  which,  they  pretend,  were 
inflicted  in  some  other  way ;  or  they  may  pretend  that  they  had 
attempted  suicide.     They  would  have  us  believe  they  fast. 

Others  are  painfully  depressed  ;  they  are  sad,  have  forebodings, 
or  are  compelled  to  the  performance  of  certain  acts.  On  this 
border-line  we  approach  the  hysterical  insanities  on  the  one 
hand,  and  the  imperative  conceptions  and  neurasthenics  on  the 
other.  A  record  of  these  morljid  manifestations  in  hysteria 
would  fill  a  long  chapter. 

Convulsive  Seizures.  Hystero-epileptic  attacks  in  their  great- 
est severity  are  not  apparently  of  so  frequent  occurrence  here  as 
in  Europe,  especially  in  France  ;  but  this  may  be  due  to  the  large 
hospitals  for  chronic  cases  where  patients  are  massed  together. 
These  convulsive  seizures  often  are  preceded  by  a  feeling  of  gen- 
eral discomfort,  or  of  hallucinations  of  vision  and  hearing,  such 
as  the  cries  and  sight  of  wild  animals.  They  are  usually  sud- 
den, but  they  may  be  preceded  by  an  "aura,"  globus  hysteri- 
cus, singing  in  the  ear,  or  obscuring  of  the  visual  field.  Eespi- 
ration  is  spasmodic  ;  consciousness  is  obscured ;  the  convulsion 
may  be  similar  to  that  of  epilepsy  of  moderate  severity.  In 
some  cases  the  body  is  thrown  into  all  sorts  of  contortions  and 
attitudes.  An  extreme  opisthotonus  may  be  present,  the  body 
bent  backwards,  resting  on  the  head  and  heels.  I  have  observed 
a  case  with  these  characteristics  in  a  student.  Or  there  ma}^  be 
various  contortions  of  the  body,  which  are  fixedly  maintained  for 
some  time.  The  legs  and  arms  are  thrown  about.  The  persons 
make  gestures  and  noises.  They  sometimes  have  religious  ideas, 
which  have  an  influence  over  the  attitudes  assumed  during 
the  convulsion  ;  or  they  have  ideas  of  demoniacal  possession, 
which  give  rise  to  hideous  facial  expressions.  Prof.  Charcot 
has  depicted,   with  illustrations,   a  number  of  these  strange 


148  NERVOUS    DISEASES    AND    INSANITY. 

attitudes  and  facial  contortions.  The  convulsive  seizures  may 
be  less  violent  and  demonstrative.  A  case  of  my  own  illus- 
trates well  the  milder  attack.  A  man,  aged  eighteen,  of  robust 
physique,  in  perfect  health,  had  never  manifested  any  tendency 
to  nervous  derangement.  One  day  driving  a  spirited  horse, 
liaving  occasion  to  get  out  of  his  carriage,  before  he  could  get 
in  again  the  animal  became  frightened  and  tried  to  run  away. 
He  caught  the  horse  b}'^  the  nose,  which  in  his  struggle  to  free 
himself  jerked  about  the  young  man,  and  finally  threw  him  some 
distance  away  ;  he  lauded  on  his  feet  without  injury.  As  the 
horse  did  not  succeed  in  getting  aw^ay  the  young  man  resumed 
his  seat  in  the  carriage  and  drove  home.  When  he  reached  home 
he  was  observed  to  be  delirious.  He  went  to  bed  ;  the  next  day 
was  unable  to  raise  the  right  leg,  and  was  apparently  paralyzed, 
as  his  family  physician  said.  His  family  were  exceedingly  solici- 
tous about  him,  especially  his  father,  who  w^atched  him  carefully, 
took  his  pulse  and  temperature,  upon  which  he  always  put  an 
erroneous  construction  and  exaggerated  importance.  Very  early 
the  young  man  began  to  complain  of  pains  in  the  back  and  of 
pain  when  he  was  moved.  A  specially  constructed  bed  was 
made  for  hiui.  Some  months  after  the  occurrence  of  the  accident 
and  the  development  of  the  paralysis  in  the  leg,  he  began  to 
have  convulsions,  not  of  great  severity  ;  but  consciousness  was 
either  clouded  or  lost.  With  this  attack  there  were  also 
associated  constantly  a  quivering  and  twitching  of  the  partly 
closed  eye-lids.  The  family  and  family  physician  took  a  most 
gloomy  view  of  the  matter,  and  when  I  made  a  diagnosis  of  an 
hysterical  condition  and  probable  favorable  prognosis,  the  father 
was  almost  offended.  The  patient  remained  in  bed  for  two  or 
three  months  longer,  when  one  day  he  suddenly  announced  that 
he  thought  he  could  walk,  and  he  got  out  of  bed  and  walked 
about.  Many  similar  cases  are  recorded  by  Charcot  and  others. 
For  further  details  on  this  very  interesting  subject  I  must  refer 
the  student  to  the  authors  whose  works  are  appended  to  this 
short  chapter. 

One  phase  of  this  condition  deserves  mention  here,  and  it  is 
the  association  of  hysterical  symptoms  with  organic  disease. 
This  association  often  leads  to  great  difficulty  in  diagnosis  even 


VASO-MOTOR    NEUROSIS.  149 

by  experienced  clinicians.     I  can  merely  allude  to  its  occurrence 
here. 

Bibliography. — Charcot,  Le§ons  sur  les  Maladies  du  Systeme 
IsTerveux,  tome  3.  — Jolly,  Hysteria,  Ziemssen's  Cyclopedia  of 
Medicine.  — Seguin,  Hysterical  Symptoms  in  Organic  Disease, 
Opera  Minora. — Putnam  and  Walton,  Journal  of  Xeurology, 
1884.— Page,  Injuries  of  the  Spine. — Mills,  Hysteria,  Pepper's 
System  of  Medicine.— Buzzard,  On  the  Simulation  of  Hysteria 
by  Organic  Disease  of  the  ISTervous  System,  Brain,  1800. — 
Mitchell,  Kervous  Diseases. 

Vaso-motor  Neurosis. 

The  bloodvessels  are  under  the  control  of  the  vaso-motor 
system  of  nerves.  There  is  a  vaso-motor  centre,  or,  as  it  is 
sometimes  called,  monarchical  vaso-motor  centre  in  the  medulla 
oblongata  ;  each  half  of  the  body  has  its  own  centre  ;  stimula- 
tion of  which  causes  contraction  of  all  the  arteries  ;  paralysis, 
dilatation  of  all  the  arteries.  Under  ordinary  circumstances 
the  centre  is  in  a  state  of  moderate  tonic  excitement.  It  may 
be  excited  directly  and  reflexly,  just  as  the  cardiac  and  respiratory 
centre  are.  Besides  this  monarchical  vaso-motor  centre  there 
are  subordinate  centres  in  the  spinal  cord  ;  injury  to  the  cord 
therefore  causes  dilatation  of  the  bloodvessels  ;  if  the  injury  is 
high  up  in  the  cord  these  subordinate  vaso-motor  centres  below 
the  seat  of  injury,  as  soon  as  they  have  recovered  from  the 
shock,  again  control  the  bloodvessels  and  restore  the  tone  of 
their  muscular  coat  ;  they  may,  how^ever,  not  do  so  completely. 
There  are  nerve-libres  whose  stimulation  causes  the  vaso-motor 
centre  to  produce  a  strong  contraction  of  the  arteries,  and  con- 
sequently a  rise  in  the  arterial  blood  pressure  ;  these  are  called 
"pressor"  fibres.  There  are  also  fibres  whose  stimulation  re- 
flexly diminishes  the  excitability  of  the  vaso-motor  centre  ; 
these  are  known  as  "depressor"  nerves.  Section  of  the  vaso- 
motor nerves,  say  in  the  cervical  sympathetic,  is  followed  by 
dilatation  of  the  bloodvessels  of  the  parts  supplied  by  it ;  there 
are  redness  and  increased  temperature  of  the  part ;  and  there 


150  NERVOUS    DISEASES    AND    INSANITY. 

may  be  increased  transudation  through  the  vessels  so  as  to  give 
rise  to  a  moderate  cedema. 

This  nervous  mechanism  may  be  injured  or  disordered  in 
the  medulla  or  in  the  spinal  cord,  the  sympathetic  ganglia,  or 
in  the  afferent  fibres.  The  vaso-motor  centre  in  the  medulla 
oblongata  is  influenced  by  the  cerebrum,  as  is  shown  by  sudden 
pallor  in  fright  or  blushing  under  some  emotion.  It  is  thought 
that  it  is  a  composite  centre,  each  part  presiding  over  a  particular 
vascular  area.  Poisons  may  excite  the  vaso-motor  nerves  or 
paralyze  them  ;  irritations  at  a  distance  may  reflexly  cause  the 
same  effect.  Tor  further  information  on  this  subject  the  student 
is  referred  to  Landois'  Physiology,  and  Yulpian's  Le9ons  sur 
L'Appareil  Yaso-moteur. 

There  are  observed,  clinically,  a  number  of  conditions  which 
are  very  evidently  due  to  disturbances  of  the  vaso-motor  system. 
The  exact  cause  of  disturbance  in  a  given  case  is  very  often 
difficult  to  determine.  Every  possible  source  of  peripheral 
irritation  should  be  investigated,  the  condition  of  the  pelvic 
organs,  the  kidneys,  liver,  heart,  stomach,  etc.  ;  it  may  be  the 
result  of  the  presence  of  some  morbid  product  in  the  blood.  It 
occurs  very  much  more  frequently  in  women  than  men,  and  in 
persons  whose  nutrition  is  defective  or  who  live  in  damp, 
malarious,  and  unhealthy  places.  It  occurs  usually  between  20 
and  40  years  of  age. 

These  disturbances  are  shown  externally  in  three  ways  :  1st. 
Intense  pallor,  temporary  in  duration,  coming  on  suddenly,  with 
lowering  of  the  temperature,  and  pain,  confined  to  some  local 
area  ;  the  fingers  are  the  most  frequently  affected,  one  or  more 
of  them  ;  for  this  reason  it  has  been  called  "digiti  mortui ;"  it 
lasts  a  few  minutes,  then  the  pallor  lessens,  the  warmth  re- 
turns, and  the  natural  appearance  is  restored  ;  these  paroxysms 
may  recur  many  times  in  a  day.  This  is  the  so-called  angio- 
spasm ;  or  the  condition  may  be  the  reverse,  there  is  an  angio- 
paralysis  ;  a  vaso-motor  paralysis.  Instead  of  pallor,  there  is  a 
mo-re  or  less  sudden  redness  in  localized  spots,  with  tingling 
sensation  ;  it  gradually  disappears  after  a  few  minutes  ;  it  may 
occur  in  one  or  both  hands. 

A  number  of  painful  vaso-motor  neuroses  have  been  described. 


VASO-MOTOR    NEUROSIS.  151 

S.  Weir  Mitchell  has  related  a  painful  burning  condition  of  the 
feet,  confined  to  the  plantar  surface  mostly,  and  in  patches  ; 
externally  the  parts  look  dusky  red ;  it  is  brought  on  by  long 
standing  or  walking;  at  first  there  may  be  a  rise  in  temperature, 
with  later  some  oedema,  swelling,  coldness,  and  pallor  in  the  part ; 
he  calls  it  "  erythemomegalalgia. "  I  have  observed  a  somewhat 
similar  painful  condition  of  the  feet  in  a  young  woman.  It  is 
most  severe  in  the  feet,  but  extends  as  high  as  the  knees  ;  both 
feet  are  affected  ;  the  pain  is  sharp  and  burning,  at  times  very 
severe  ;  there  is  a  very  slight  duskiness,  no  swelling  or  oedema  ; 
the  temperature  is  not  lowered.  For  the  past  twelve  years  she 
has  suffered  this  painful  condition  during  the  summer  months  ; 
she  is  perfectly  free  from  it  during  the  cold  weather  of  autumn, 
winter,  and  spring.  The  pain  is  relieved  by  walking  or  stand- 
ing ;  this  is  the  reverse  of  Mitchell's  case.  One  is  not  unfre- 
quently  consulted  at  the  clinics  and  in  private  practice  by 
sufferers  from  a  painful  condition  of  the  hands  and  arms  ;  it 
may  come  on  at  any  time,  and  is  persistent ;  it  is  not  accom- 
panied by  any  changes  in  color  or  temperature  ;  it  is  often  worse 
at  night,  and  appears  to  be  influenced  by  the  seasons  and  ex- 
ternal temperature.  In  marked  contrast  with  the  condition  of 
this  young  woman,  who  suffers  only  in  the  summer,  is  that  of 
women  who  only  suffer  in  the  winter  ;  in  these  cases  the  pain 
begins  in  the  fingers  of  both  hands  on  the  approach  of  cold 
weather,  with  paroxysms  of  angio-spasm,  which,  on  subsiding, 
are  succeeded  by  paralytic  dilatation,  so  that  the  hands  become 
dark  purple,  swollen,  painful ;  and  ulcerations  occur,  usually  at 
the  ends  of  the  fingers.  These  ulcerations  begin  by  severe  pain 
in  the  end  of  a  finger  ;  then  there  is  observed  a  small  black  spot 
— a  small  hemorrhage — (note  the  similarity  between  this  con- 
dition and  the  ecchymotic  spots  in  locomotor  ataxia)  which  grad- 
ually changes  into  brown  (as  the  extra vasated  blood  is  altered) 
followed  by  ulceration  with  loss  of  tissue.  The  hands  now  be- 
come so  painful,  swollen,  and  purple  that  they  cannot  be  used. 
On  the  approach  of  warm  weather  this  condition  improves  ;  but 
there  still  remains  evidence  of  the  ulcerations.  The  skin  of  the 
fingers  is  glossy,  the  nails  slightly  ridged,  and  the  fingers  are 


152  NERVOUS    DISEASES    AND    INSANITY. 

of  a  lower  temperature  than  normal.     Both  hands  are  aflected, 
and  all  the  toes  to  a  less  degree. 

A  similar  condition,  which  is  still  more  marked,  was  first  de- 
scribed by  Kaynaud  in  1862,  and  has  since  been  called  Raynaud's 
disease  ;  symmetrical  gangrene  ;  local  asphyxia.  It  may  begin 
in  the  same  way  as  some  of  the  conditions  above  mentioned,  but 
this  is  not  usual. 

The  disease  begins  somewhat  suddenly  as  a  localized  pallor  *, 
the  hands  are  most  frequently  aflected,  then  the  feef  ;  or  it  may 
be  more  general,  when  it  aflects  the  hands,  feet,  tip  of  the  nose, 
and  both  ears.  I  have  recently  seen  an  extreme  case  of  this 
kind  with  Dr.  Rich,  of  this  city.  The  pallor  is  accompanied  with 
some  pain  of  a  tingling,  burning  character,  but  it  is  not  severe. 
This  is  follow^ed  by  a  dusky  appearance  of  the  parts,  which 
gradually  deepens,  finally  becomes  black  and  intensely  cold  ; 
hence  the  name  symmetrical  gangrene  given  to  it.  It  is  usu- 
ally confined  to  the  first  phalanx  of  the  fingers  and  toes,  the  tip 
end  of  the  nose,  and  the  upper  part  of  both  ears  ;  its  extent 
varies  in  each  finger ;  there  is  great  danger  of  sloughing ;  the 
pulse  may  be  feeble  ;  the  person  looks  distressed  and  anxious  ; 
he  makes  no  complaint  of  discomfort.  The  manifestations  of 
the  vaso-motor  neurosis  are  numerous,  but  there  is  a  marked 
general  similarity  among  them. 

Prognosis.  In  some  cases  it  is  a  most  unfavorable  condition 
as  far  as  recovery  is  concerned  ;  such  was  the  result  in  Mitchell's 
cases.  In  others  improvement  occurs.  The  severe  cases,  sym- 
metrical gangrene,  appear  to  recover  more  frequently  than  any 
others. 

Treatment.  This  must  be  directed  to  discover  any  sources  of 
peripheral  irritation,  or  the  presence  in  the  blood  of  abnormal 
products,  etc. 

A  great  deal  has  been  done  in  the  way  of  medication,  often 
without  satisfactory  results.  If  the  general  health  is  poor,  a 
building-up  treatment  should  be  adopted  :  tonics,  quinine,  ar- 
senic, strychnia,  with  ample  nutritious  diet,  residence  in  a 
healthy  dry  locality,  with  out-of-door  life,  and  freedom  from 
anxiety  if  that  be  possible.  Galvanism  to  the  spine  has  been 
used.     In  severe  cases  the  vascular  spasm  may  be  relieved  by 


VASO-MOTOR    NEUROSIS.  153 

belladoima  ;  or  chloral  may  be  used  to  relieve  the  pain,  provided 
the  condition  of  the  heart  does  not  contraindicate  its  use.  The 
parts  should  be  kept  warm  with  hot  dry  flannel.  If  the  pulse  is 
feeble,  stimulants,  or  small  doses  of  morphia  and  digitalis  may 
be  given. 

Bibliography.— T.  A.  McBride,  New  York  Medical  Record, 
1878. — Barlow,  London  Clinical  Society  Transactions,  1883.— 

Chas.   K.  Mills,   American  Journal  Medical  Sciences,   1878. 

Allan  McL.  Hamilton.  — S.  C.  Clark,  Medical  Eecord  (N.  Y.), 
1885.— C.  L.  Dana,  Medical  Record,  1885.— J.  C.  Shaw,  New 
York  Medical  Journal,  1886.— M.  A.  Starr,  Pepper's  System  of 
Medicine. 


154  NERVOUS    DISEASES    AND    INSANITY. 


SECTION  V. 
INSANITY. 


CHAPTER  L 

The  Simple  Insanities  not  Connected  with  Degenerative 
Neuropathic  States. 

It  may  be  well  at  the  beginning  of  this  section  to  briefly  state 
what  are  understood  by  a  few  of  the  terms  which  are  in  constant 
use  in  mental  diseases.  They  are  not  definitions,  but  explana- 
tions. It  is  very  difficult  to  define  some  of  these  terms  to  suit 
everybody.  If  we  understand  their  application  in  mental  dis- 
eases, that  will  suffice  for  the  present. 

Hallucinations  of  hearing,  vision,  taste,  smell,  and  tact  are 
quite  common  in  the  insane  ;  and  the  frequency  with  which  they 
are  present  is  in  the  order  in  which  they  are  here  given. 

Hallucinations  are  the  perception  of  objects,  sounds,  tastes, 
smells,  etc.,  when  they  do  not  really  exist.  If  a  person  says 
he  sees  men  outside,  and  there  are  no  men  there,  he  has  an 
hallucination  of  vision.  If  he  says  he  hears  a  child  shrieking, 
when  there  is  no  child  shrieking,  he  suffers  an  hallucination  of 
hearing. 

A  person  may  have  hallucinations,  and  yet  be  sane ;  mentally 
he  can  correct  the  erroneous  perception. 

Illusion  is  the  misinterpretation  of  the  character  of  an  object, 
which  is  really  perceived.  If  a  man  sees  a  piece  of  clothing 
hanging  on  a  chair  in  his  room,  and  says  it  is  a  bear,  or  if,  seeing 
a  lamp-post,  he  says  it  is  a  man,  he  is  suffering  from  an  illusion. 

Delusions  are  false  ideas,  the  result  of  disturbances  in  reason- 
ing. If  a  man  says  he  sees  men  outside  his  house  with  guns, 
when  no  men  with  guns  are  there,  he  has  an  hallucination  of 
vision.     If  now  he  says,  contrary  to  the  evidence  of  others, 


INSANITY.  155 

that  they  are  there,  that  they  are  coming  hi  to  shoot  him,  he 
has  a  dekisiou  based  upon  his  halkicination. 

But  he  may  also  have  these  erroneous  ideas  witliout  the 
hallucinations  ;  he  may,  from  a  general  disturbance  in  his  rea- 
soning faculties  and  vague  feelings  of  distress,  say  that  he  has 
committed  some  crime  (which  he  is  unable  to  give  any  evidence 
of),  and  is  to  be  hanged  to-morrow  ;  he  suffers  from  a  delusion. 

Imperative  conceptions  are  ideas  which  are  not  strictly  de- 
lusions. The  person  well  knows  their  absurdity,  and  can  reason 
about  them,  but  they  rise  in  his  consciousness  unbidden,  and 
over  them  he  has  no  control. 

Melancholia. 

The  characteristic  of  this  disease  is  a  profound  mental  dis- 
turbance, varying  from  simple  depression  to  the  most  violent 
despair,  w^ith  agitation  or  passive  resignation.  By  the  degree 
in  which  this  depression  presents  itself,  we  can  recognize  a 
simple,  passive,  agitated,  and  attonita  variety. 

It  develops  slowly  and  progressively  as  the  result  of  dis- 
turbances in  the  physical  and  mental  state,  such  as  prolonged 
mental  emotions,  which  impair  the  strength  of  the  nervous  sys- 
tem. General  disorders  of  nutrition,  the  result  of  gastro-intes- 
tinal  affections,  severe  loss  of  blood,  as  after  parturition,  lacta- 
tion, loss  of  sleep,  painful  neuralgias,  and  more  recently  Iagri2jpe, 
have  been,  by  their  depressing  influences,  causes  of  this  dis- 
order. If  these  causes  act  upon  a  nervous  system  predisposed 
to  the  disease  by  reason  of  an  inherited  or  acquired  neuropathic 
state,  the  resistance  is  less  great  than  in  a  healthy  nervous  or- 
ganization. 

It  begins  by  a  general  mental  depression,  forebodings,  discour- 
agement, irritability.  The  patient  loses  interest  in  home  and 
family  and  neglects  his  work  ;  sleep  is  poor,  appetite  fails  ;  women 
have  attacks  of  crying  and  grow  thin  ;  the  bowels  are  consti- 
pated, and  the  tongue  may  be  coated.  This  condition  may,  in 
the  mildest  cases,  end  in  simple  melancholia.  But  often  pa- 
tients become  restless  and  sleepless  at  night ;  they  experience 
all  sorts  of  uncomfortable  sensations  in  the  head  ;  the  feeling 


156 


NERVOUS    DISEASES    AND    INSANITY. 


of  depression  increases  ;  and  they  have  all  manner  of  forebodiiifj^s 
and  dread.     They  are  unable  to  account  for  their  condition.     If 

Fig.  45. 


Melancholia.    Quiet,  but  with  intense  anxiety.    (Drawn  from  a  photograph.) 

their  intellect  is  sufficiently  disturbed,  they  connect  the  depres- 
sion with  the  idea  that  they  have  done  wrong,  either  by  com- 
mitting an  unlawful  act  or  neglecting  the  performance  of  some 
service  to  God  or  to  their  children  :  or  some  trivial  act  of  their 
life  is  recalled,  which  is  judged  by  them  to  render  them  liable 
to  punishment.  These  thoughts  take  complete  possession  of 
them  ;  they  can  think  of  nothing  else.  They  walk  about  from 
place  to  place,  perhaps  wringing  their  hands,  and  reveal  con- 
stantly their  morbid  ideas  ;  the  facial  expression  becomes  anx- 
ious and  distressed. 
They  neglect  all  their  duties.     Even  eating  and  dressing  are 


INSANITY. 


157 


abandoned,  and  they  go  about  with  disordered  clothing  and 
hair.  They  may  manifest  delusions  that  they  are  to  be  car- 
ried to  jail  or  punished  in  some  way  for  the  (supposed)  wrongs 
they  have  committed.     They  look  out  of  the  windows  anxiously 

Fig.  46. 


Melancholia  passive.    This  attitude  is  retained  day  after  day  ;  answers  are 
given  in  a  very  low  tone.    (Drawn  from  a  photograph.) 


(the  least  noise  attracts  them),  to  see  if  some  one  is  not  coming  ♦ 
to  carry  them  off  to  execution,  to  the  jail,  or  to  an  asylum  ;  or 
they  imagine  that  there  is  a  conspiracy  to  poison  them  ;  or  they 
lament  that  some  calamity  is  about  to  happen  to  their  family, 
or  that  their  property  is, being  taken  away  from  them,  etc.  They 
can  give  no  reason  for  these  beliefs.    This  condition  may  develop 


158  NERVOUS    DISEASES    AND    INSANITY. 

itself;  the  delusions  may  become  overpowering,  and  the  intellect 
be  profoundly  disturbed.  They  believe  they  may  be  shot ;  they 
see  persons  coming  to  injure  them.  Every  one  who  approaches 
them,  they  think,  is  about  to  do  them  harm.  They  have  illu- 
sions ;  see  in  the  things  about  the  room  and  outside  the  figures 
of  men,  hangmen,  or  men  with  guns,  wild  beasts  (this  is  most 
decided  toward  the  evening,  when  everything  is  in  shadow). 
They  suspect  some  danger  is  concealed  behind  every  nook 
and  corner  of  the  room,  and  every  moment  anticipate  that 
some  one  will  come  in  through  the  door.  They  have  hallu- 
cinations of  smell  at  times,  and  think  they  smell  blood  and 
dead  bodies. 

They  have  hallucinations  of  hearing,  such  as  the  shrieks  of 
persons  being  killed,  their  children  perhaps  ;  threats  of  torture  ; 
the  applying  to  them  of  vile  names,  etc.  In  this  terrified  condi- 
tion they  will  often  rush  about,  try  to  get  out  of  the  windows 
and  doors,  call  for  help,  and  attack  those  about  them,  especially 
if,  in  their  confusion,  they  believe  they  are  ahout  to  be  injured. 
Under  these  circumstances  they  pay  no  attention  to  their  ap- 
pearance, take  no  food  or  water,  and  do  not  attend  to  the  calls 
of  nature.  Often  the  agitation  is  so  great  that  it  alone  prevents 
them  from  taking  food  and  drink.  If  they  take  water,  they 
hastily  swallow  a  few  mouthfuls,  looking  about  them  in  a  sus- 
picious, anxious  manner,  and  then  run  away  ;  or  they  may  re- 
fuse food  and  drink  as  the  result  of  delusions  of  poisoning,  or 
from  hallucinations  as  to  the  smell  of  dead  bodies,  etc.  This  is 
the  agitated  melancholia.  All  these  melancholies  may  attempt 
suicide,  either  to  rid  the  world  of  their  worthless  selves,  or  to 
avoid  the  persecutions  and  tortures  which,  they  think,  are  about 
to  be  inflicted  upon  them. 

In  the  passive  form  the  reverse  of  these  conditions  is  seen. 
Patients  are  quiet,  resigned,  and  remain  in  one  place  and  one 
•  attitude  for  days,  weeks,  or  months.  The  expression  shows  dis- 
tress, but  not  terror,  as  in  the  agitated  form.  If  they  reply,  it 
is  in  a  low  tone  and  indistinct.  Visits  of  friends  make  no  im- 
pression on  them.  They  are  annoyed  by  any  effort  to  change 
their  position,  and  they  resist  passively.  In  the  melancholia 
attonita,  consciousness  is  paralyzed  in  the  highest  degree  ;  they 


INSANITY. 


159 


arc  under  the  influence  of  painful  impressions  ;  tliey  are  stupid 
remain  in  one  position,  and  at  night  they  do  not  sleep  ;  they 
place  themselves  in  the  most  uncomfortable  positions ;  remain 
in  a  fixed  attitude,  with  head  bent  on  chest,  arms  flexed  or 

Fig.  47. 


Annie  D.,  aged  19;  decided  hereditary  history.    Plallucinations  of  hearing, 
marked  agitation,  delusions  of  demouiaeal  possession.    Eecovery. 

crossed  over  the  chest  in  a  state  of  profound  stupor ;  they  are 
cold  and  cyanosed  ;  there  are  marked  nutritive  and  vascular 
disturbances;  there  may  be  a  paralytic  oedema  of  feet  and 
hands,  pulse  is  feeble,  secretions  are  diminished  ;  they  lose 
flesh.  It  is  with  difficulty  that  these  patients  are  made  to 
eat ;  they  have  to  be  dressed  and  undressed,  and  put  to  bed, 
and  they  may  make  much  resistance  to  these  efforts  to  serve 
them. 

A  considerable  proportion  of  these  cases  will  recover,  but  the 


160  NERVOUS    DISEASES    AND    INSANITY. 

prognosis  is  not  so  favorable  as  in  mania.  Eecovery  takes 
place  slowly,  and  there  are  often  periods  of  exacerbation  in  the 
course  of  convalescence.  The  person  laments  less,  or  his  agi- 
tation is  lessened.  Then  he  begins  to  take  a  momentary  no- 
tice of  things  about  him,  then  more  interest.  In  some  cases  it 
may  be  from  three  months  to  six  or  nine  months  before  recovery 
takes  place.  If  he  does  not  recover  he  passes  either  into  chronic 
melancholia,  or  into  dementia  more  or  less  marked. 

Treatment.  Must  consist  in  the  removal  of  any  diseased  con- 
dition of  the  viscera  ;  relief  of  constipation  ;  a  liberal  nutritious 
diet,  and  wine.  With  a  good  deal  of  patience,  persons  may  be 
induced  to  eat  sufficiently,  and,  in  the  milder  cases,  even  to  take 
medicines,  which  should  consist  of  tonics,  and  small  doses  of 
opium  or  morphia,  with  a  moderate  amount  of  exercise  out  of 
doors,  not  enough  to  produce  fatigue.  If  they  remain  sleepless, 
some  hypnotic  should  be  given  at  bedtime.  A  milk-punch  or  a 
glass  of  ale  may  sometimes  give  the  desired  sleep  ;  or  a  small 
dose  of  camphor  in  oil,  combined  with  tinct.  lupulin,  or  chloral, 
urethan,  sulphonal,  or  paraldehyde  may  be  used  ;  the  objection 
to  the  last  is  its  disagreeable  taste,  which  remains  all  the  next 
day.  In  the  more  agitated  cases  there  is  much  diflSculty  in 
feeding  patients,  and  a  stomach-tube  may  have  to  be  resorted 
to  before  they  will  eat.  They  will  take  no  medicines ;  hence 
small  doses  of  morphia  should  be  given  unknown  to  them  in 
coffee,  or,  if  the  agitation  be  very  great,  hypodermically. 

Mania. 

The  maniacal  state  is  the  reverse  of  the  melancholic  ;  there  is 
an  over-activity  of  all  the  mental  functions  ;  ideas  flow  with  ab- 
normal rapidity  ;  persons  conceive  all  kinds  of  projects  in  rapid 
succession  ;  their  physical  activity  corresponds  to  their  mental 
exaltation ;  they  are  in  constant  motion ;  all  the  perceptions  and 
the  memory  are  keen ;  they  recall  readily  past  occurrences,  plunge 
precipitately  from  one  idea  to  another,  and  speak  constantly. 
The  facial  expression  is  animated,  but  rapidly  and  frequently 
changes ;  they  are  irritable  and  suspicious ;  they  cannot  bear 
the  least  opposition  or  contradiction,  readily  become  angry  and 


INSANITY.  161 

violent.  They  are  the  victims  of  their  rapidly-changing  ideas 
and  impulses.  There  is  a  feehng  of  personal  importance.  Men 
organize  all  sorts  of  business  plans,  give  contradictory  orders, 
or  make  plans  for  enjoyment  without  regard  to  expense.  They 
go  to  excess  in  wine  and  women,  smoke  incessantly,  are  in 
constant  motion.  Women  make  efforts  to  display  their  ac- 
complishments in  works,  piano-playing,  singing,  etc.  They 
are  self-satisfied  ;  they  feel  themselves  competent  to  the  ac- 
complishment of  any  project.  In  mild  cases  the  association  of 
ideas  may  remain  logical,  but  as  they  become  more  and  more 
rapid,  abundant,  and  disorderly,  they  become  confused.  The 
muscular  movements  also  become  wild  and  disorderly.  Con- 
sciousness becomes  clouded ;  attention  and  perception  are  im- 
possible. Illusions  and  hallucinations  may  occur,  but  they  are 
not  a  part  of  the  ordinary  symptomatology,  and  they  play  no 
part  in  the  delirium.  They  are  now  in  constant  motion  and 
gesticulating;  they  cry,  laugh,  dance  about;  lose  all  sense 
of  decency.  The  exaggeration  of  personality  may  lead  them 
to  say  they  are  kings,  queens,  great  actors,  musicians,  or 
statesmen. 

All  the  sensations  are  exalted  ;  light  and  noise  disturb  them. 
They  may  remove  their  clothing  to  relieve  themselves  of  ex- 
cessive warmth.  They  appear  to  suffer  no  muscular  fatigue.  In 
simple  cases  there  is  no  elevation  of  temperature  ;  the  pulse 
varies  ;  it  may  be  full  and  rapid.  If  the  paroxysm  lasts  long, 
and  they  take  little  food  and  lose  sleep,  their  weight  diminishes 
rapidly. 

The  prognosis  is  very  favorable  in  these  simple  cases.  If 
recovery  does  not  occur,  it  is  followed  by  mental  enfeeblenient — 
dementia. 

Treatment.  AEay  the  nervous  irritability.  They  should  be 
isolated  ;  they  should  be  induced  to  take  plenty  of  food,  if  that 
is  possible.  Bromide  of  soda  in  full  doses  may  be  needed  to 
quiet  the  excitement,  and  sleep  should  be  procured  at  night  by 
chloral  and  morphia,  or  sulphonal ;  a  dose  or  two  of  hyoscy- 
amine  at  intervals  may  be  necessary.  Cold  baths  may  diminish 
the  excitement.  If  they  lose  flesh,  and  the  pulse  grows  weak, 
11 


162  NERVOUS    DISEASES    AND    INSANITY. 

wine  should  be  given  with  the  food.     Tepid  baths  may  also  be 
found  beneficial. 

Senile  Dementia. 

It  Is  the  result  of  the  physical  changes  in  the  brain,  atheroma, 
endarteritis,  and  periarteritis  ;  general  disturbances  in  nutri- 
tion, localized  atrophies,  together  with  the  changes  in  the  other 
organs  found  in  senility.  It  may  begin  at  any  time  after 
50  years  of  age.  It  begins  usually  with  irritability,  which  is 
the  expression  of  defective  nutrition  of  the  brain  ;  they  become 
apathetic,  suffer  a  general  state  of  malaise,  vertigo,  and  insomnia. 
The  memory  becomes  defective  for  recent  events,  while  they 
can  recall  past  events.  As  the  condition  progresses,  they  be- 
come obstinate  and  unreasonable,  and  often  suspicious.  They 
may  think  their  house  will  be  broken  into  by  thieves  ;  this 
makes  them  very  anxious  ;  thej'^  take  extra  precautions  in  fast- 
ening up  the  windows,  and  sometimes  at  an  unusually  early 
hour  of  the  evening,  or  they  may  believe  their  goods  are  being 
carried  away  and  their  families  will  starve.  They  become  rest- 
less at  night,  get  up  and  wander  about  at  times  looking  for 
thieves  ;  in  other  instances  they  can  give  no  reason  for  their  wan- 
derings. As  the  condition  progresses  they  eat  freely,  forgetting 
soon  afterwards  that  they  have  had  their  meal,  and  calling  for 
another  ;  or  they  may  go  to  alcoholic  excesses  in  the  same  way  ; 
forgetting  that  they  have  taken  a  drink,  they  take  another.  In 
spite  of  this  consumption  of  food  they  grow  thin  and  haggard, 
the  face  pale,  and  the  skin  wrinkled  and  shrivelled.  They  lose 
all  sense  of  propriety,  make  obscene  and  coarse  remarks,  or 
expose  their  persons,  or  go  about  partly  dressed,  when  they  had 
in  health  been  particular  as  to  behavior  and  dress,  or  they  may 
make  foolish  marriages,  or  assaults  upon  girls.  The  general 
mental  state  in  these  persons  is  that  of  depression,  but  there 
may  be  exaltation  to  a  moderate  degree.  As  the  disease  pro- 
gresses, the  defect  in  memory  becomes  great  ;  they  get  lost  in 
their  wanr^crings,  forget  their  house,  the  names  and  number  of 
their  children.  They  may  suffer  apoplectiform  seizures,  grow 
more  and  more  feeble  ;  the  disposition  to  wander  away  may 


INSANITY.  163 

become  very  troublesome  ;  it  is  sometimes  done  with  the  idea 
that  they  are  not  in  their  own  house  ;  they  may  suffer  from 
cystitis,  and  are  liable  to  have  pneumonia.  They  gradually 
fail,  grow  weaker  mentally  and  physically,  develop  bed  sores, 
perhaps  diarrhoea,  and  die  ;  often  Cheyne  Stokes  respiration  ap- 
pears at  the  last.  Old  people  sometimes  have  attacks  of  ordi- 
nary insanity,  such  as  melancholia,  mania,  etc. ;  then  the  mental 
changes  are  those  found  in  those  states,  and  are  not  included 
under  senile  dementia.  The  dementia  after  cerebral  hemor- 
rhage, tumor  and  other  gross  brain  disease  is  also  not  included 
under  this  head. 

The  duration  of  this  condition  varies  very  much  ;  it  may  be 
rapid,  especially  if  complications  arise,  otherwise  it  lasts  from 
about  one  to  three  years. 

Treatment  can  only  be  palliative.  They  have  to  be  cared  for 
like  children.  Some  hypnotic  may  be  given  them  at  night,  such 
as  urethan,  camphor,  sulphonal,  etc. 

Dementia  Terminal. 

This  refers  to  the  mental  enfeeblement  which  is  secondary  to 
uncured  acute  attacks  of  mental  disease.  There  may  be  such  a 
profound  mental  enfeeblement  that  perception  is  completely 
abolished  ;  the  facial  expression  is  blank,  without  a  trace  of 
animation  even  for  a  moment ;  they  sit  in  one  place  all  day, 
with  the  head  down  ;  only  take  food  when  it  is  taken  to  them,  or 
they  to  it ;  then  they  eat  voraciously  and  carelessly  whatever  is 
put  before  them  ;  they  have  to  be  dressed  and  undressed  ;  they 
pass  their  urine  and  faeces  where  they  are,  unless  attended  to, 
in  the  profoundest  cases  ;  they  make  no  reply  to  questions,  in- 
telligence is  too  much  impaired  to  comprehend.  In  this  state 
of  vegetative  life  they  may  grow  fat.  Others  can  reply  ''  Yes" 
and  "  jSTo"  to  questions,  but  there  is  a  good  deal  of  uncertainty 
as  to  which  should  be  the  answer.  In  others  the  state  of  men- 
tal impairment  is  not  so  great  ;  they  can  remember  fairly 
well  some  subjects,  and  they  are  able  to  perform  simple  acts, 
which  by  habit  they  have  learned,  and  requiring  no  reflection 
and  judgment.     Their  association  of  ideas  is  defective,  all  the 


164  NERVOUS    DISEASES    AND    INSANITY. 

sentiments  are  very  much  impaired  or  abolished.  Others  are 
restless,  walk  about  constantly,  and  are  annoyed,  if  disturbed. 
Often  this  condition  of  dementia  follows  rapidly  upon  the  un- 
cured  acute  mental  disturbance  ;  in  others  it  approaches  slowly, 
being  preceded  by  a  state  of  mental  confusion  and  incoherence. 
It  is  sometimes  possible  to  learn  the  nature  of  the  primary 
mental  disorder  from  the  fragmentar}^  expression  of  delusions 
which  had  previously  existed  in  full  force  ;  in  others  it  is  im- 
possible to  do  so  without  a  history. 


CHAPTER   11. 

The  Begenerative  Insanities. 

The  transmission  of  mental  and  physical  peculiarities  from 
ancestors  to  descendants  is  well  known,  the  likeness  to  parents 
in  face,  actions,  and  bodily  shape. 

There  may  also  be  a  transmission  of  abnormal  states  mental 
and  physical,  or  only  a  predisposition  to  their  development 
under  exciting  causes.  Hereditary  transmission  may  be  direct, 
so  that  the  descendants  present  the  same  abnormal  nervous 
manifestations  ;  as  in  the  transmission  of  hemicrania,  epilepsy, 
or  the  same  mental  disorder.  A  parent  suffering  melancholia, 
a  child  may  have  the  same,  even  the  same  morbid  ideas ;  and 
these  states  may  arise  in  the  offspring  at  the  same  age  they  did 
in  the  ancestors.  If  the  two  parents  are  neuropathic,  the  trans- 
mission is  greater.  If  only  one  parent  is  neuropathic,  the 
mother  has  a  greater  influence,  as  a  rule,  than  the  father.  A 
suicidal  tendency  is  often  transmitted  ;  so  that  many  members 
of  a  family  may  commit  suicide.  This  trait  then  becomes  an 
evidence  of  neuropathic  transmission  ;  it  is  said  that  the  influ- 
ence of  the  father  is  most  strong  in  this  direction.  Numerous 
instances  of  transmission  can  be  easily  found  by  any  student  or 
physician. 

I  have  met  an  epileptic  man,  who  by  his  first  wife  had  one 
child,  a  daughter  ;  she  became  epileptic  ;  he  married  a  second 
time,  and  had  one  child,  also  a  daughter  ;  she  became  epileptic 


INSANITY.  1G5 

at  seventeen  years  of  age.  The  transmissions  are  not  always  of 
the  same  disease  ;  thus  insanity  in  a  family,  the  descendants  may 
suffer  from  chorea,  epilepsy,  or  insanity,  and  these  persons  are 
more  liable  to  have  general  paralysis  of  the  insane  than  others. 
Alcoholic  excesses  in  the  parents  are  liable  to  predispose  their 
descendants  to  cerebral  and  other  nervous  disorders. 

In  the  simple  transmission  of  a  neuropathic  constitution,  the 
power  of  the  organism  to  resist  disease  is  diminished  but  there 
is  no  lesion.  But  the  transmission  may  be  associated  with  evi- 
dences of  physical  or  mental  degenerations,  such  as  the  phy«ical 
and  mental  defects  of  idiots  and  imbeciles,  obliquities  in  the 
mental  state,  imperative  conceptions,  fanciful  ideas,  etc.  There 
may  be  an  over-development  of  one  faculty  (for  mathematics  or 
for  music)  and  the  marked  enfeeblement  of  all  the  others ;  or 
there  may  be  deformities  of  the  head,  face,  mouth,  body,  hands, 
or  feet,  or  in  the  great  vessels  of  the  body,  etc.,  or  constitutional 
anaemia,  which  may  play  in  these  families  an  important  part  in 
the  nutritional  changes  in  the  nervous  system  and  other  organs 
and  perhaps  explain  the  associations  of  phthisis,  epilepsy,  and 
insanity  in  the  family  and  its  branches. 

The  student  must  refer,  for  further  information  on  this  im- 
portant and  interesting  subject,  to  other  works,  and  first  of  all 
to  Morel,  Traite  des  Degenerescences  de  I'Espece  Humaine, 
Paris,  1857. — P.  Lucas,  Traite  des  Physiologique  et  Philoso- 
phique  de  PHeredite  Naturelle. — Ribot,  Heredity  (translation), 
D.  Appleton  &  Co.,  K.  Y.:  and  to  other  works  on  insanity  given 
at  the  end  of  this  book. 

Paranoia. 

The  subjects  of  this  condition  inherit  a  neuropathic  constitu- 
tion, they  often  have  from  birth  physical  abnormalities  ;  in  the 
shape  of  the  head  or  the  body  development ;  they  are  over- 
sensitive, eccentric,  and  odd  ;  they  have  strange  ideas  ;  they  are 
impelled  to  absurd  acts  by  imperative  conceptions  ;  they  are 
distrustful,  given  to  excesses  and  masturbation.  They  may 
go  through  hfe  without  presenting  further  mental  obliquity.    In 


166  NERVOUS    DISEASES    AND    INSANITY. 

others  at  the  approach  of  puberty,  or  the  diraacteric,  with  their 
disturbing  elements,  they  may  develop  mental  disorder.  Or 
upon  excesses  of  all  kinds,  privation  of  food,  anxieties,  over- 
work and  loss  of  sleep,  they  may  develop  acute  delirium,  cha- 
racterized by  intense  hallucinations.  In  those  cases  which 
develop  at  puberty,  it  may  be  of  the  type  of  a  mild  melancholia 
or  mania,  with  more  or  less  stupor  and  confusion,  and  rapidly 
pass  into  dementia.  At  a  later  period  of  life  it  develops  into  an 
active  delirium,  sensorial  in  character,  with  depressed,  or  ex- 
alted ideas.  Delirium  of  persecution,  with  intense  hallucinations 
of  hearing  of  terrifying  nature,  from  which  they  may  recover 
more  or  less  suddenly.  There  is  great  danger  of  relapses,  and 
the  possibility  later  of  the  development  of  fixed  delusions,  hallu- 
cinations, and  illusions. 

The  chronic  form  is  the  most  marked,  and  it  usually  begins 
as  depression,  the  result  of  some  mental  or  physical  strain. 
They  become  a  prey  to  painful  ideas,  perplexities,  and  anxieties  ; 
sleep  and  appetite  are  lost ;  they  have  a  vague  suspicion  that 
people  about  them  do  not  wish  them  well,  they  desire  to  get 
them  out  of  their  occupations,  or  to  throw  upon  them  the  blame 
of  their  errors.  As  this  strained  condition  of  over-sensitiveness 
increases,  they  keep  to  themselves,  avoid  people,  think  people 
in  the  street  are  specially  observing  them  ;  the  frequent  meeting 
of  a  person  makes  them  suspicious  of  him  ;  they  are  annoyed 
and  offended  by  trivial  remarks  ;  they  think  the  people  passing 
cough  or  "suck  their  teeth"  at  them  so  as  to  annoy.  They  are 
the  constant  prey  of  painful  ideas.  They  apply  to  themselves 
remarks  they  hear  in  casual  conversation.  This  continues  until 
at  last  they  believe  they  are  the  subject  of  conspiracy  and  perse- 
cution. They  may  gradually  or  suddenl}-  develop  hallucinations, 
hear  voices  threatening  them,  calling  them  vile  names ;  the  voicc;s 
come  from  all  directions,  even  from  their  own  body.  Thej'  ap- 
peal to  the  police  for  protection.  May  develop  the  idea  that  they 
are  the  victims  of  a  conspiracy  by  Jesuits,  Freemasons  ;  or  that 
electrical  and  telephonic  machines  are  in  some  way  made  to  act 
upon  them.  They  may  have  hallucinations  of  smell  and  taste  ; 
they  are  poisoned  at  night  b}?^  obnoxious  gases,  and  resort  to  all 
kinds  of  stranire  devices  to  obtain  fresh  air ;  or  the  food  tastes 


I^'SANITY.  107 

of  dead  bodies,  arsenic,  and  other  poisons  ;  their  drink  contains 
urine,  they  smell  chloroform  and  stop  up  the  key-holes  in  con- 
sequence. They  frequently  change  their  place  of  residence  to 
avoid  these  persecutions.  Women  hear  themselves  called  pros- 
titutes and  insulting  propositions  made  to  them.  They  may 
talk  freely,  or  answer  the  physician's  questions  with  suspicion  ; 
remain  in  bed  and  refuse  food.  They  may  remain  in  this  con- 
dition for  months  or  years.  There  may  be  temporary  ameliora- 
tion in  the  activity  of  the  delusions  and  hallucinations,  with 
relapses.  Change  of  residence  often  gives  rise  to  these  improve- 
ments, but  soon  these  delu^^ions  are  as  strong  as  ever  ;  they  think 
their  enemies  have  discovered  them.  The  ideas  may  very  soon 
become  fixed  and  systematized. 

They  may  have  disturbances  of  cutaneous  sensibility,  think  ani- 
mals are  in  their  bodies,  sexual  liberties  are  taken  with  them  at 
night,  their  viscera  are  displaced  or  drawn  up.  They  may  have 
delusions  of  poisoning,  when  they  refuse  food,  but  will  hve  on 
raw  eggs,  or  cook  their  own  food.  Hallucinations  of  vision  are 
rare.  The  delusions  here  are  like  those  in  melancholia,  but 
they  differ,  in  that  the  person  seeks  for  an  explanation  of  his 
distressed  mental  state  in  the  external  world  or  his  surround- 
ino-s,  and  concludes  that  he  is  the  victim  of  a  conspiracy  ;  while 
in  melancholia  he  finds  in  himself  the  explanation  of  his  feelings  ; 
it  is  a  punishment  upon  him  for  his  crimes  and  misdeeds.  At 
first  they  endure  passively  their  persecutions,  but  later  they 
become  defiant,  threaten  their  supposed  persecutors,  appeal  to 
the  court  and  police  for  protection  and  redress  ;  finding  no  help 
they  become  aggressive,  and  are  then  exceedingly  dangerous  ; 
they  may  on  the  least  suspicion  take  the  life  of  any  one  around 
them,  or  perform  some  brutal  act  often  with  the  idea  of  calling 
public  attention  to  their  persecutions,  and  thus  obtain  redres?. 
They  never  murder  secretly,  but  openly.  They  may  pass  into  a 
state  of  physical  weakness,  or  there  may  occur  a  change  in  the 
delirium.  They  think  they  notice  they  are  observed,  and  are 
the  special  object  of  attention  and  respect  by  great  personages, 
actors,  actresses,  statesmen,  etc.,  as  they  pass  them  by.  The 
newspapers  hint  at  their  noble  birth  ;  they  are  the  son  or  daugh- 
ter of  a  king,  a  large  fortune  awaits  them  ;  or  they  are  very 


168 


NERVOUS    DISEASES    AND    INSANITY. 


learned,  poets  and  writers,  great  inventors,  or  have  a  wonder- 
ful theory,  or  they  are  the  suitors  of  some  person  of  distinction 
(Dougherty  thought  he  was  the  suitor  of  Mary  Anderson  ;  when 
confined  in  an  asylum  he  shot  an  assistant  physician,  having 
included  among  his  persecutors  the  oflScers  of  the  institution) ; 
or  they  travel  from  a  distant  city  to  have  an  interview  with  a 

I'lG.  48. 


Paranoia,  delirium  of  grandeur.  Says  she  is  "  Queen  of  Heaven."  Dresses  (as 
shown)  with  a  crown  made  of  pasteboard,  decorated  with  feathers,  beads,  paper, 
and  ribbon.    (Drawn  from  a  photograph.) 

young  lady  of  wealth  they  never  saw.  At  this  stage  the  whole 
attitude  and  manner  show  the  exalted  ideas.  In  others  the 
ideas  of  grandeur  are  expressed  in  a  feeble  manner ;  they  are 
queen  of  heaven,  etc.,  the  Messiah,  8on  of  God. 


INSANITY.  1G9 

The  delirium  of  grandeur  developed  explains  to  them  the 
cause  of  their  persecution  ;  it  was  to  deprive  them  of  their  in- 
heritance or  to  prevent  their  marriage. 

These  chronic  cases  are  incurable ;  they  undergo  a  certain 
mental  enfeeblement,  but  there  is  no  tendency  to  dementia ; 
when  confined  in  an  asylum  they  live  for  years,  comparatively 
contented. 

Hysterical  Insanity. 

The  hysterical  temperament  is  its  foundation,  it  is  very 
variable.  There  is  an  extreme  change  of  state  ;  it  is  much 
influenced  by  disturbed  conditions  of  the  sexual  apparatus, 
feebleness,  physical  and  psychological ;  the  reflexes  are  over- 
active ;  they  are  thrown  into  convulsive  states  with  great  ease  ; 
they  are  emotional  and  imaginative  ;  impressionable  ;  there  are 
often  sudden  intellectual  confusion  and  incoherent  ideas  ;  they 
are  fond  of  being  eccentric  and  attracting  attention ;  their 
behavior  is  such  as  they  think  most  calculated  to  make  them 
interesting.  They  are  egotistic  ;  they  neglect  their  own  occu- 
pations to  engage  in  useless  benevolent  work.  Others  are  dis- 
agreeable, quarrel  with  their  friends  and  abuse  their  families  so 
that  they  cannot  live  at  home.  They  are  suliject  to  intense 
hallucinations  of  a  fanciful  character.  They  have  either  ex- 
cessively strong  sexual  desires  or  the  reverse,  and  are  sometimes 
given  to  self-abuse.  They  exaggerate  their  pains,  and  accuse 
tiiose  about  them  of  unkindness ;  they  pretend  resignation  to 
their  state.     They  are  usually  unfavorable  cases  for  recovery. 

Periodic  Insanities. 

They  are  evidence  of  hereditary  transmission  of  a  neuropathic 
state.  They  are  characterized  by  the  periodic  recurrence  of 
their  attacks  :  Periodic  mania,  periodic  melancholia,  and  cir- 
cular insanity. 

Periodic  Mania  is  in  some  respects  very  similar  to  ordinary 
mania ;  it  is  often  preceded  by  a  state  of  irritability,  quarrel- 


170  NERVOUS    DISEASES    AND    INSANITY. 

someness,  and  dissatisfaction,  depression,  disagreeable  sensa- 
tions. Tiiey  may  go  to  excess  in  drinking,  etc.,  abuse  their 
families  and  those  about  them  ;  the  attacks  may  begin  early  in 
life  or  at  the  climacteric.  In  a  more  decided  way  they  become 
quite  violent,  and  break  and  destroy  things  about  them.  In  a 
few  days  it  may  subside  ;  the  onset  of  these  attacks  is  more  apt 
to  be  sudden  than  in  the  simple  mania  and  melancholia.  Others 
may  have  religious  ideas  or  think  tiiey  have  enemies  about 
them,  and  suffer  from  hallucinations,  and  more  or  less  complete 
mental  confusion  ;  they  have  sudden  attacks  of  destroying  every- 
thing about  them.  They  may  express  ambitious  ideas  ;  be 
haughty,  but  confused  in  their  ideas  ;  it  is  possible  sometimes  to 
gain  their  attention  for  a  few  seconds.  The  facial  expression  is 
animated,  there  is  constant  confused  talking  ;  in  the  absence  of 
confusion  they  may  accuse  those  about  them  of  injustice,  and 
make  complaints.  They  cannot  remain  quiet  a  moment,  move 
from  place  to  place,  make  all  sorts  of  gestures,  destroy  things 
about  them,  pick  the  plaster  away  froui  the  walls,  tear  up  all 
their  clothing  until  they  are  naked,  may  expose  themselves  with 
evident  sexual  excitement.  Others  make  curious  braids  and 
ornaments  with  the  pieces  of  torn  clothing  and  bedding,  which 
they  tie  around  their  head  and  waist ;  stick  feathers  or  whisks 
of  broom  in  their  hair.  They  may  use  vile  language  ;  sing  and 
shout  night  and  day.  The  duration  of  these  attacks  varies  from 
a  few  days  to  several  weeks  ;  it  usually  ceases  gradually  with  at 
times  slight  relapses  for  several  days  or  weeks  before  the  quiet 
interval  is  established.  The  time  of  interval  between  the  at- 
tacks varies.  Mentally  they  are  not  normal,  often  presenting  a 
number  of  pathological  traits  which  they  showed  in  an  aggra- 
vated form  during  the  maniacal  seizure.  Usually  these  attacks 
are  exactly  alike. 

Peeiodic  Melancholia  is,  like  the  melancholia,  observed  in 
a  healthy  brain,  but  its  onset  is  sudden,  like  periodic  mania,  and 
it  passes  away  more  or  less  rapidly. 

Circulak  Insanity. — Its  characteristics  are  alternating 
attacks  of  mania  and  melancholia,  or  melancholia  and  mania. 


INSANITY. 


171 


The  mania  is  like  the  fhild  mania  of  common  type— a  state 
of  over-activity  and  excitation,  mentally  and  physically.     They 
are  constantly  occupied  with  some  project  or  business  scheme. 
They  are  egotistic,  fault-finding,  make  complaints  against  the 
authorities,  or  the  officers  of  institutions  ;  annoy  and  irritate 
those  about  them,  then  threaten  them  ;  move  about  constantly, 
engage  in  (if  allowed  to  do  so)  first  one  business,  then  in  another, 
without  any  regard  to  their  fitness  for  its  prosecution,  means  to 
carry  it  on,  or  prospect  of  profit.     One  patient  whom  I  have  seen 
wrote  letters  to  large  business  houses  ordering  large  quantities  of 
merchandise  of  various  kinds  ;  they  spend  money  recklessly,  go 
to  excess  in  drinking,  etc. ;  they  have  exalted  ideas  of  their  own 
importance,  and  not  unfrequently  hypochondriacal  ideas,  but  tliey 
are  not  expressed  in  a  gloomy  way.    They  think  they  have  kid- 
ney or  heart  disease,  and  wish  to  be  examined  ;  they  w^rite  con- 
stantly long  essays  or  letters,  or  they  draw  all  kinds  of  figures 
and  designs,  which  they  show  with  satisfaction,  as  remarkably 
well  done— perhaps  designs  for  mansions  and  stables  they  intend 
to  erect.     These  are  always  curious  and  grotesque.     Women 
are  coquettish,  and  try  to  make  a  display  of  accomplishments 
they  do  not  possess.     They  talk  and  move  about  incessantly. 

The  melancholic  stage  is  of  the  type  of  common  melancholia. 
The  passive  form  is  the  most  frequent.  They  become  quiet, 
avoid  people,  keep  the  house,  have  a  dread  that  something  will 
happen  to  them.  Hallucinations  are  rare,  but  they  may  have 
delusions  that  they  are  to  be  carried  away  ;  they  speak  less  and 
less  ;  the  facial  expression  becomes  apathetic  and  dull ;  if  they 
speak,  it  is  in  a  low  tone  ;  they  remain  in  one  position,  with  head 
and  eyes  down  ;  they  may  refuse  to  eat,  and  have  to  be  urged  ; 
they  may  go  to  bed  on  the  appearance  of  this  stage,  and  remain 
there  during  its  continuance.  They  are  apathetic,  dull,  and 
stupid  ;  they  cannot  be  induced  to  get  up.  During  this  stage 
they  lose  flesh,  if  the  refusal  to  eat  is  marked  ;  the  secretions 
are  diminished,  the  bowels  constipated,  circulation  impaired, 
hands  and  feet  cold  and  blue,  pulse  small. 

In  the  maniacal  state  this  is  just  reversed  ;  all  the  functions 
are  active  ;  they  eat  heartily,  grow  stout,  circulation  and  secre- 
tions active. 


172  NERVOUS    DISEASES    AND    INSANITY. 

The  most  common  type  is  the  melanchoUa  followed  by  the 
mania  ;  the  passage  from  one  state  to  the  other  may  be  sudden 
or  gradual,  without  any  interval ;  the  duration  of  each  phase  of 
this  cycle  varies ;  it  may  be  as  short  as  a  day,  or  it  may  last 
several  months.  Often  the  duration  of  each  phase  is  alike, 
say  melancholia  six  months,  mania  six  months  ;  but  it  may 
be  unlike,  as  in  the  case  of  a  girl  under  my  care,  in  which  the 
melancholic  stupor  lasted  a  year,  and  the  maniacal  stage  three 
or  four  months.  After  the  cycle  has  been  run,  there  may  be  an 
interval  of  apparent  mental  health  ;  but  it  is  more  common  to 
have  that  interval  a  shading  off  of  one  or  other  of  the  phases. 
As  the  condition  becomes  more  pronounced,  they  pass  from  one 
cycle  to  the  other  for  the  rest  of  their  lives.  The  diagnosis 
rests  in  these  cases  upon  the  history,  or  observation  of  periodi- 
city. 

Epileptic  Insanity. 

The  epileptic  state  has  already  been  described.  Insanity  may 
follow  the  epileptic  convulsion — post-epileptic  insanity.  It  may 
precede  the  convulsive  seizure.  It  may  take  the  ]3lace  of  the 
convulsive  seizure,  or  it  may  terminate  in  dementia. 

After  one  or  more  epileptic  seizures,  there  may  be  a  sleep 
of  short  duration,  which  may  be  followed  by  a  state  of  light 
stupor,  during  which,  or  following  it,  there  is  a  state  of  fright 
and  terror  with  disturbance  of  consciousness  more  or  less  com- 
plete. The  stupor  may  be  prolonged  for  days  ;  it  may  be  deep, 
or  only  a  confused  dazed  state  in  which  they  mutter  to  them- 
selves, repeat  words  or  sentences,  move  about  from  side  to  side  in 
a  restless  manner.  They  may  be  constantly  asking  questions  and 
making  complaints  or  demands.  They  have  difficulty  in  speak- 
ing, which  is  indistinct  and  hesitating ;  their  movements  may 
be  slow,  awkward,  and  trembling.  Consciousness  is  profoundly 
disturbed.  After  the  attack  has  subsided,  they  may  indistinctly 
and  in  a  fragmentary  manner  recall  certain  things  which  have 
occurred.  Or  there  may  be  a  state  of  anxiety,  irritability,  and 
excitement  (post-epileptic  delirium),  the  result  of  hallucinations 
of  a  terrifying  nature.    They  are  thrown  into  a  state  of  wild  ex- 


INSANITY.  173 

citement  and  fury,  in  which  they  break  objects ;  injure  themselves 
and  others  ;  tlie  face  is  congested,  eyes  and  conjunctiva  injected, 
facial  expression  that  of  terror  and  fury,  eyes  more  or  less  fixed 
and  wild  ;  arteries  throb.  At  the  end  of  a  few  hours  or  a  few 
days  they  quiet  down  gradually,  sleep  ;  after  which  there  is  a 
light  state  of  stupor  or  confusion.  They  complain  of  headache, 
feeling  bad  and  tired ;  during  the  excitement  they  neither  eat 
nor  drink ;  now  they  Ijegin  to  take  food.  The  hallucinations  are 
terrifying  :  they  see  God,  the  heavens  opening,  angels  and  devils, 
hear  music,  or  terrifying  noises.  The  violence  is  sudden  and 
furious,  and  directed  against  persons  and  objects  around  them, 
with  indifference  ;  a  parent  kills  his  child  by  suddenly  dashing 
it  against  the  wall  (a  case  which  came  under  my  personal  ob- 
servation). They  may  mutilate  themselves.  In  other  cases 
the  maniacal  seizure  may  precede  the  convulsion  ;  they  are 
irritable,  strange,  restless,  asking  innumerable  questions,  and 
making  demands,  become  more  and  more  agitated  ;  this  is 
followed  by  a  convulsive  seizure,  after  which  they  may  pass 
into  a  sleep,  followed  by  a  confused  state,  and  recovery  of 
their  former  selves,  or,  after  the  convulsion,  there  may  be  the 
wild  excited  state,  as  in  cases  of  post-epileptic  delirium.  Or 
the  convulsive  seizure  may  be  replaced  by  a  maniacal  attack 
similar  to  the  post-epileptic  deUrium ;  they  may  have  all  the 
terrifying  hallucinations,  or  not ;  they  sing,  shout,  break  up 
every  thing  about  them.  A  very  marked  illustration  of  this 
condition  has  come  under  my  observation  in  a  young  mulatto. 
The  paroxysm  was  ushered  in  suddenly  with  extreme  violence  ; 
he  would  break  everything  about  him,  sing  at  the  top  of  his 
voice,  eyes  more  or  less  fixed,  facial  expression  rigid,  as  if  the 
muscles  were  in  a  state  of  tension  ;  but  there  was  no  look  of 
terror  ;  his  songs  were  those  familiar  to  us  ;  this  excitement  and 
singing  he  would  continue  night  and  day. 

There  may  be  maniacal  attacks  which  last  weeks  and  months 
with  marked  disturbances  of  consciousness,  illusions,  and  hallu- 
cinations of  a  distressing  character,  marked  ill-temper,  fault- 
finding, with  religious  ideas,  a  disposition  to  acts  of  violence, 
and  a  tendency  to  end  in  dementia. 

There  are  also  seizures  more  or  less  sudden  (and  these  are 


174  NERVOUS    DISEASES    AND    INSANITY. 

not  succeeded  by  convulsion),  in  which  the  person  is  seized 
with  dread,  terrifying  ideas,  a  dazed  state  of  consciousness, 
with  impulses  to  suicide,  or  acts  of  violeuce  to  others,  and  there 
is  a  disposition  to  wander  away  from  his  residence  ;  it  is  of 
short  duration — a  few  days. 

There  are  also  seizures,  very  much  like  peiii  maZ,  in  which 
there  is  sudden  and  temporary  confusion,  disturbed  conscious- 
ness, during  which  they  j)erform  apparently  voluntary  motor 
acts  (automatic  acts),  such  as  attempts  at  suicide,  or  homicide, 
thefts,  setting  fire  to  places,  rape,  etc.  There  is  complete  amne- 
sia.    They  are  of  short  duration. 

During  the  convulsive  seizures  there  is  elevation  of  tempera- 
ture and  increased  pulse-rate. 

Epileptics  are  often  profoundly  egotistic  ;  they  think  only  of 
themselves,  and  observe  minutely  all  the  acts  of  their  vegeta- 
tive life  ;  they  are  indifferent  to  those  about  them  ;  they  are 
irritable,  easily  offended,  and  the  least  opposition  to  their  wishes 
gives  rise  to  vague  ideas  of  persecution.  On  the  other  hand, 
they  are  often  easily  made  sociable  and  pleased  by  small  atten- 
tions and  acts  of  kindness  or  a  few  kindly  words.  They  are 
frequently  excessively  religious,  speak  only  of  God  and  religion, 
sing  hymns,  and  read  the  Bible.  This  excessive  religious  feeling 
may  precede  a  maniacal  attack.  They  are  often  defiant,  quar- 
relsome, and  fault-finding.  In  the  majority  of  these  cases  they 
gradually  pass  into  a  state  of  dementia. 

Treatment.  These  epileptic  insanities  are  best  treated  in  asy- 
lums. In  the  maniacal  attacks  it  is  necessary  to  isolate  them  ;  if 
the  maniacal  excitement  is  prolonged,  so  as  to  cause  exhaustion, 
narcotics  must  be  given — chloral  is  the  best.  The  treatment 
otherwise  is  the  same  as  epilepsy,  but  usually  less  successful. 
In  the  maniacal  seizures,  which  replace  the  convulsive  attacks, 
the  best  results  are  sometimes  derived  from  the  use  of  full  doses 
of  bromide  of  soda  or  potassa. 


Alcoholic  Insanity. 

There  is  a  peculiar  neuropathic  state  which  in  some  persons 
gives  rise  to  a  craving  for  stimulants,  and  especially  alcohol — 


INSANITY. 


173 


such  as  the  dipsomaniac,  who  periodically  is  impelled  to  take 
his  first  drink,  and  then  suddenly  plunges  into  the  depths  of 
alcoholic  intoxication,  to  emerge  from  it  somewhat  quickly  after 
several  days  or  months,  with  a  period  of  freedom  and  absti- 
nence, or  in  the  case  of  a  person  whose  whole  character  is  irri- 
table, disagreeable,  a  burden  to  himself  and  those  about  him,  an 
increase  in  this  irritable  state  precedes  an  imperative  desire  to 
drink.  But  all  patients  are  not  of  this  type,  but  may  be  indi- 
viduals who  with  inducements  have  acquired  a  habit  of  drinking 
for  years,  have  thus  lowered  the  tone  of  their  nervous  organi- 
zation, weakened  their  will  power,  so  that  they  no  longer  control 
themselves.  Their  organs  are  all  more  or  less  diseased  ;  fatty 
changes,  increase  of  connective  tissue,  especially  in  the  liver  and 
kidneys,  have  occurred.  There  is  no  relation  between  the  amount 
of  alcohol  taken  and  the  mental  symptoms  ;  as  persons  with  a 
neuropathic  constitution  bear  alcohol  very  badly  ;  and  a  com- 
paratively small  quantity  taken  by  them  will  set  up  a  train  of 
morbid  mental  symptoms  not  found  in  others. 

After  a  few  days  or  weeks  of  alcoholic  excess,  hallucina- 
tions, delusions,  and  illusions  of  a  terrifying  character  are  de- 
veloped ;  voices  threaten  and  taunt  them.  Delusions  that 
lie  is  to  be  killed  or  injured  by  these  men  ;  thinks  he  sees 
these  men  coming  after  him ;  at  night  he  hears  multitudes 
of  threatening  voices  of  men  and  devils  outside  his  house 
trying  to  get  in  ;  he  has  illusions,  in  that  he  mistakes  the 
lamp-posts  for  men  with  guns,  or  a  wagon  for  a  hearse  to  put 
him  in  ;  the  objects  in  the  room  may  be  mistaken  for  men,  or  he 
may  have  vivid  hallucinations  of  vision,  seeing  numbers  of  men 
outside.  He  becomes  intensely  terrified  ;  either  shouts  for  help, 
or  attempts  to  hide,  or  prepares  to  defend  himself  Such  a  man 
is  dangerous.  In  one  case  which  I  have  seen,  the  man  had  hal- 
lucinations of  vision  ;  he  saw  the  floors,  walls,  and  the  bodies  of 
those  about  him  covered  with  long,  sharp,  steel  spikes,  which 
they  intended  to  thrust  into  him  ;  in  his  terror  he  drew  a  pocket- 
knife  and  stabbed  a  man  near  him  ;  or  he  may  believe  the  world 
is  coming  to  an  end,  see  angels  and  the  devil. 

Others  are  depressed  ;   think  they  are  about  to  die  ;  hear 
voices  calUng  them  vile  names  ;  in  women,  accusations  of  pros- 


176  NERVOUS    DISEASES    AND    INSANITY. 

titution  ;  threats  to  kill  them,  or  turn  them  out  of  their  houses  ; 
or  the  delusion  that  they  have  some  loathsome  disease.  They 
have  a  marked  tendency  to  injure  themselves  by  mutilation ; 
sometimes  the  most  terrible,  such  as  putting  their  heads  in  a  hot 
stove,  or  burning  themselves  over  the  abdomen  and  penis  with 
hot  coals,  which  are  drawn  from  a  fire  with  the  hands,  or  ham- 
mering off  the  penis  ;  another  makes  efforts  to  gouge  out  his 
eyes  ;  hanging  and  strangulation  are  also  attempted.  These 
terrifying  ideas  are  greatest  at  night ;  they  are  sleepless,  and 
may  refuse  food  under  the  idea  that  it  is  poisoned.  They  lose 
weight,  look  pale  ;  pulse  rapid  and  irregular,  running  up  during 
a  period  of  intense  terror ;  tongue  coated,  breath  offensive. 
Barely,  there  may  be  epileptic  seizures  ;  or  the  delirium  may  not 
be  so  active  ;  but  there  is  a  decided  delusion  of  persecution,  with 
hallucinations  of  hearing ;  they  hear  persons  calling  them  vile 
names  and  accusing  them  of  crimes,  using  blasphemous  phrases  ; 
they  may  develop  delusions  of  marital  infidelity  ;  these  delusions 
are  almost  characteristic  of  alcoholic  insanity,  and  its  subjects 
are  dangerous  individuals.  In  others  there  may  be  an  hallu- 
cinatory stupor,  with  restlessness,  which  may  entirely  subside 
in  a  few  days. 

There  may  be  a  gradual  mental  enfeeblement,  a  dementia, 
with  defective  memory  for  recent  events.  There  may  be  sen- 
sory disturbances  in  these  cases,  depending  upon  neuritis.  (See 
Alcoholic  Neuritis.) 

In  the  more  acute  cases  the  prognosis  is  always  favorable. 
If  there  is  a  gradual  and  steady  mental  enfeeblement,  recovery 
is  only  partial ;  if  the  alcoholic  excesses  are  continued,  there  is 
ultimately  complete  mental  enfeeblement.  There  may  be  an 
apparent  dementia,  from  which  they  may  recover  partially  or 
entirely. 

Treatment.  Must  be  abstinence  from  alcohol.  In  the  acute 
conditions  it  may  be  necessary  to  give  morphia  to  quiet  the  ter- 
rifying hallucinations  ;  chloral  may  have  to  be  given  to  procure 
sleep.  It  may  be  necessary  to  give  hyoscyamine  or  hyoscine  ; 
it  should  be  given  once  and  under  the  physician's  direction,  and 
not  repeated  without  his  seeing  the  patient  again.     As  much 


INSANITY.  177 

food  should  be  given  as  they  can  be  induced  to  take.     The 
secretions  should  be  ke^Dt  active. 

Imperative  Conceptions. 

Under  this  head  is  included  a  variety  of  abnormal  mental 
states.  The  sufferers  from  it  may  be  insane,  but  most  commonly 
they  are  not ;  they  reason  and  think  correctly,  recognize  the 
absurdity  of  their  ideas,  and  often  occupy  important  positions 
in  life.  They  are  most  frequently  met  with  in  private  practice 
or  at  the  clinics.  It  is  characterized  by  a  sudden  bursting  into 
consciousness  of  ideas  or  words  which  have  no  connection  with 
the  existing  train  of  thouglit ;  it  surprises,  confuses,  and  dis- 
tresses ;  it  is  beyond  the  control  of  the  individual ;  no  effort  pre- 
vents the  sudden  appearance  of  these  morbid  ideas.  They  are 
not  unfrequently  connected  with  the  curious  and  fanciful  ideas 
of  the  person.  It  is  always  found  in  persons  of  a  neuropathic 
inheritance,  and  there  may  or  may  not  be  evidences  of  degenera- 
tion. One  of  my  patients  always  felt  an  irresistible  desire  to  tell 
persons  he  saw  to  do  some  harm  ;  if  he  saw  a  child,  to  tell  it  to 
break  things  or  set  the  place  on  fire.  Euffianly-looking  men  gave 
rise  to  the  desire  to  tell  them  to  kill  or  do  some  harm.  These 
imperative  conceptions  are  often  associated  with  a  feeling  of  doubt 
as  to  their  having  performed  some  act ;  this  man  often  doubted 
if  he  had  told  these  persons  to  do  harm  ;  with  difficulty  he  freed 
himself  from  the  impression  that  he  had.  Under  this  general 
head  have  been  described  a  variety  of  morbid  states,  such  as 
folie  de  doute,  folie  de  toucher,  mysophobia  (fear  of  contamina- 
tion) of  Hammond,  agarophobia,  claustrophobia,  etc. 

In  its  simplest  form  this  condition  is  sometimes  observed  in 
neurasthenics,  and,  perhaps,  women  suffer  from  it  oftener  than 
men  ;  it  occurs  in  persons  who  inherit  a  neuropathic  constitution, 
who  have  evidences  of  degeneration  ;  but  it  may  be  found  in 
persons  v,dio  present  no  evidence  of  degeneration.  It  is  brought 
on  by  illness,  which  lowers  the  general  nutrition,  loss  of  blood, 
anxiety,  privations  ;  gastro-intestinal  disorders  play  an  import- 
ant part  in  setting  it  up.  The  disorders  of  the  intestinal  tract 
have  a  most  wonderful  intluence  in  disturbing  the  nervous 
12 


178  NERVOUS    DISEASES    AND    INSANITY. 

systems  of  these  persons.  In  its  simplest  form  it  is  manifested 
by  a  dread  of  fatal  disease  which  they  doubt  their  physician's 
knowledge  of,  or  tliey  doubt  the  propriety  of  his  treatment. 
They  watch  with  anxiety  all  their  functions  and  sensations, 
interrogate  their  physician  and  friends.  It  is  constantly  mani- 
fested by  a  dread  of  going  out  of  doors  alone  ;  they  fear  they 
will  fall  in  the  street,  or  have  some  kind  of  an  attack,  or  that 
something  will  happen  to  them,  they  cannot  explain  what.  The 
moment  they  attempt  to  go  out  this  imperative  idea  comes  upon 
them  ;  they  become  anxious,  tremble,  perspiration  breaks  out ; 
they  are  flushed,  feel  hot,  and  faint ;  a  feeling  of  suffocation  and 
weakness  of  the  legs  comes  over  them.  They  are  conscious  of 
the  absurdity  of  the  idea  ;  many  try  to  overcome  it  by  going 
out ;  in  others  the  idea  and  dread  are  so  strong,  that  the  moment 
they  attempt  to  go  out,  this  idea,  with  all  its  accompanying 
sensations,  comes  upon  them.  Others  have  a  dread  of  crossing 
the  river  or  travelling  on  a  railroad  train  ;  an  idea  comes  to 
them  that  something  will  happen,  when  they  are  at  once  thrown 
into  terror ;  one  of  my  patients  always  said  he  became  "  panicky. " 
Cold  perspiration  would  break  out  upon  him ;  he  was  in  terror 
until  off  the  car  ;  he  knew  the  absurdit}?-  of  the  idea  and  dread, 
but  could  not  overcome  them.  Or  a  woman  may  have  the  idea 
that  the  needles  she  uses  will  do  some  harm.  A  painter  fears 
that  in  some  way  he  has  poisoned  a  w^ell.  These  imperative 
ideas  may  be  of  a  homicidal  nature.  A  young  girl,  at  the  sight 
of  knives,  has  an  imperative  conception  to  kill  her  mother ;  she 
is  perfectly  conscious  that  it  would  be  unnatural  and  a  crime ; 
she  tries  to  overcome  it,  but  is  unable  ;  tliis  throws  her  into  a 
state  of  distress  and  anxiety,  in  which  she  cries  and  begs  to  be 
helped. 

Or  the  imperative  ideas  may  take  the  form  of  questioning  on 
religious  and  metaphysical  subjects,  such  as  "Who  am  I?" 
"Who  is  God?"  "What  am  I  doing  here?"  "Am  I  alive?" 
etc.  Or  they  may  be  of  a  vulgar  character,  and  these  are  fre- 
quently associated  with  religion.  In  devotions  the  idea  of  the 
sexual  apparatus  of  the  Virgin  Mary  suddenly  arises  and  con- 
stantly recurs.  To  a  good  Eoman  Catholic  this  is  a  most  ter- 
rible thought.     He  tries  to  overcome  it,  consults  his  priest ;  but 


INSANITY.  179 

the  idea  constantly  recurs  in  spite  of  his  efforts.     I  Iiave  met  a 
number  of  cases  with  this  idea.     Or  it  may  take  tlie  form  of 
curses  on  the  Virgin  Mary  and  God.     One  of  my  patients  con- 
stantly had  "  blasphemous  thoughts"  about  God  ;  if  he  spat 
upon  the  floor,  he  thought  he  had  spat  upon  God.     These  ideas 
were  to  him  sins.    Tiie  result  was  he  at  once  prayed  for  forgive- 
ness wherever  he  was,  on  a  street  or  public  conveyance  ;  and 
as  the  imperative  ideas  recurred  very  frequently  he  was  most 
of  the  time  praying.     A  well  marked  form  of  this  state  is  the 
mysophobia  {folie   de  doute;  folie  de  toucher).     It  usually  be- 
gins, in  a  well-marked  case,  with  doubt  as  to  their  having  per- 
formed some  act  properly  ;  this  is  soon  followed  by  a  dread  of 
dirt,  contamination.     A  characteristic  of  these  cases  is  frequent 
washing  of  the  hands,  with  the  imperative  idea  they  are  dirty. 
Once  washed  they  doubt  their  being  clean  ;  this  leads  to  an- 
other washing  and  repetitions.     In  one  of  ni}^  cases  the  mother 
suffered  imperative  conceptions  when  young.      The  child  was 
peculiar  from  birth  ;  cried  constantly,  was  irritable,  slept  little. 
Early  in  life  had  whooping-cough,  during  which  there  were  fre- 
quent convulsions  ;  later,  a  severe  attack  of  chorea.    As  a  child, 
was  peculiar  in  eating  ;  never  asked  for  sweet  things,  preferred 
salt ;  ate  at  irregular  times.     After  leaving  school  engaged  in  a 
business,  when  his  first  decided  symptoms  began.     His  hands 
became  dirty  from  the  dust  and  his  work.     This  induced  him 
to  wash  them  ;  but  they  still  felt  dirty,  so  he  washed  again,  and 
it  soon  became  a  frequent  operation,  as  he  had  constantly  recur- 
ring doubts  as  to  their  cleanliness.     At  about  the  same  time, 
after  arranging  articles  about  the  store,  he  doubted  his  having 
arranged  them  properly  and  had  to  return.     The  sight  of  the 
objects  did  not  satisfy  him  that  they  were  properly  placed  ;  the 
imperative  conception  was  so  strong  that  he  had  to  rearrange 
them.     This  desire  to  wash  the  hands  became  stronger  and 
more  frequent.    Soon  other  imperative  conceptions  were  added  : 
the  chairs  upon   which  his  parents   sat  he  thought  dirty  and 
would  not  use  them  ;  the  door-knobs  were  dreaded,  he  avoided 
touching  doors  and  knobs,  abandoned  using  a  night-key,  had  a 
special  dread  of  the  bath-room  door,  also  the  baluster  of  the 
stair  ;  this  caused  him  to  assume  a  peculiar  attitude  when  going 


180  NERVOUS    DISEASES    AND    INSANITY. 

down  or  up  staius,  so  as  to  avoid  touching  the  bahister  on  one 
side  and  the  wall  on  the  other.  At  night  he  spent  hours  get- 
ting ready  for  bed,  frequently  washing  the  hands,  arranging 
and  rearranging  the  articles  about  the  room.  All  these  dreads 
turned  upon  the  idea  of  contamination.  Now  he  began  to  have 
an  imperative  idea  that  he  must  roll  up  his  night-clothes  eleven 
times  before  he  could  put  them  on  ;  all  this  was  repeated  in  the 
morning.  In  others  there  is  an  idea  of  poison  getting  on  them, 
or  that  the  knives  are  dirty  ;  food  cut  with  them  is  unclean,  and 
in  consequence  there  is  refusal  of  food  cut  with  knives.  One 
little  boy  I  have  seen  thought  by  touching  objects  and  people 
he  would  get  "blood  poisoning."  The  dread  of  door-knobs, 
knives,  objects  made  of  metal,  is  very  commoil  with  these  suf- 
ferers. They  are  perfectly  conscious  of  the  abnormality  in  their 
mental  states,  but  are  powerless  ;  all  their  endeavors  to  correct 
these  conceptions  are  ineffectual ;  they  only  become  confused, 
suffer  headache,  and  are  thrown  into  such  a  state  of  anxiety 
they  usually  abandon  all  ef!brls  and  resign  themselves  to  their 
fate. 

Another  class  of  cases,  not  frequently  met  with,  however,  are 
the  sufierers  from  perverted  sexual  instincts.  It  is  an  anoma- 
lous sexual  state  in  which  men  are  attracted  sexually  towards 
men,  and  women  towards  women.  It  is  an  imperative  impulse; 
it  occupies  the  thought  of  the  individual :  they  recognize  their 
abnormal  state  and  often  lament  it,  while  others  defend  their 
actions  and  perverted  feelings.  They  have  no  pleasure  in  the 
association  with  those  of  the  opposite  sex.  They  may  be  un- 
able to  have  sexual  intercourse  ;  if  they  can,  it  is  not  accom- 
panied with  any  gratification.  They  have  erections  only  in  the 
presence  of  men.  They  may  gratify  their  perverted  instinct  by 
contact  with  the  object  of  their  love,  or  by  mutual  onanism,  or 
by  sodomy,  but  this  is  rare.  They  take  great  pleasure  in  watch- 
ing the  naked  forms  of  their  own  sex. 

They  may  have  all  the  appearance  of  normal  individuals. 
Others  have  a  feminine  appearance,  when  they  are  really  men  ; 
are  fond  of  puerilities,  of  things  which  interest  women,  have  a 
special  aptitude  for  millinery,  etc.  The  relation  of  the  history 
of  one  of  these  individuals  will  best  illustrate  the  condition  ;  it 


INSANITY.  181 

is  reported  by  Krueg.  K.  belonged  to  a  neuropathic  family  ; 
his  mother  was  hysterical,  a  sister  similarly  aft'ected,  and  a 
brother  shot  himself.  When  six  years  of  age  the  sight  of  naked 
men  in  a  bath  gave  him  peculiar  pleasure.  From  nine  to  four- 
teen years  was  nervous,  the  result  of  a  friglit,  and  was  sent  into 
the  country  on  account  of  his  delicate  health.  Learned  the 
practice  of  onanism  from  his  school-fellows.  At  this  time  con- 
ceived an  extravagant  fondness  for  one  of  his  *' friends,"  in 
which,  at  last,  sexual  desire  and  jealousy  came  to  pla}^  the 
same  part  that  they  ordinarily  do  in  love  affairs.  Pound  no 
pleasure  in  the  sports  of  his  comrades.  Later,  devoted  himself 
successfully  to  millinery  ;  ladies'  bonnets  were  his  particular 
specialty,  and  he  possessed  singular  taste  in  designing  new 
shapes  and  trimmings.  "Was  thirt^^-three  years  of  age,  in  good 
pecuniary  circumstances,  had  no  desire  to  marry  or  liave  chil- 
dren. Had  an  insuperable  abhorrence  of  sexual  connection  with 
women.  Continued  to  practice  onanism  alone  and  with  other 
men.  Confirmed  the  statement  made  by  others  that  individuals 
affected  with  this  abnormity  are  able  to  recognize  one  another. 
His  imagination  would  dwell  on  the  male  sex  only,  although  he 
did  all  that  he  could  to  direct  it  to  the  opposite  sex.  Men  ap- 
peared to  him  in  his  dreams.  He  resolved  to  leave  off  all  inter- 
course with  men,  but  since  the  resolve  had  experienced  a  con- 
stantly increasing  mental  irritation,  as  he  could  not  gratify  his 
stronger  sexual  appetite.  Complained  of  various  nervous  sen- 
sations ;  had  inherited  the  fear  which  his  mother  had  of  any- 
thing pointed,  such  as  pins.  At  times  lost  the  power  of  con- 
trolling his  thoughts ;  was  unable  to  banish  certain  ideas 
(Zwangvorstellung).  For  instance,  during  the  mass  for  his 
dead  brother  was  compelled  to  think  of  a  combination  of  the 
Host  and  the  anus  of  a  dog -a  horrifying  thought  to  a  believing 
Catholic  like  himself.  Patient  was  of  medium  size,  with  nor- 
mal genital  organs,  a  sparing  growth  of  beard  carefully  shaven, 
affected  in  dress  and  demeanor  ;  speech  and  gestures  theatrical. 
The  clinical  picture  in  these  cases  of  perverted  sexual  instinct 
is  exceedingly  varied  and  curious.  Krafft  Ebing,  one  of  the  best 
writers  on  this  state,  summarizes  the  subject  in  the  following 
manner : — 


182  NERVOUS    DISEASES    AND    INSANITY. 

a.  Congenital  absence  of  sexual  feeling  towards  the  opposite 
sex,  at  times  even  disgust  of  sexual  intercourse. 

h.  This  defect  occurs  in  a  physically  completely  differentiated 
sexual  type  and  normal  development  of  the  sexual  organs. 

c.  Absence  of  the  psychical  qualities  corresponding  to  the 
anatomical  sexual  type,  but  the  feelings,  thoughts,  and  actions 
of  a  perverted  sexual  instinct. 

d.  Abnormally  early  appearance  of  sexual  desire. 

e.  Painful  consciousness  of  the  perverted  sexual  desire. 
/.  Sexual  desire  toward  the  same  sex. 

g.  The  sexual  desire  remains  purely  platonic  or  finds  gratifi- 
cation in  mutual  onanism  or  in  feeling  of  the  object  of  the  affec- 
tions. Often  there  is  self-pollution,  but  for  the  want  of  some- 
thing better.     (Archiv.  f.  Psychiatric,  B.  YII.) 

For  further  information  on  this  subject  refer  to  J.  C.  Shaw 
and  G.  IST.  Ferris,  Perverted  Sexual  Instinct,  Journal  of  Nervous 
and  Mental  Disease,  1883,  where  a  summary  of  cases  is  given 
and  one  by  the  authors. — Blumer,  G.  A.,  American  Journal  of 
Insanity,  1882.— Tarnowsky,  Die  Krankhaften  Erscheinungen 
des  Geschlechtssinnes,  1886.  This  monograph  has  a  complete 
list  of  references  to  date. 

Hypochondria. 

It  is  always  developed  in  those  who  have  a  predisposition,  by 
inheritance,  to  mental  and  nervous  disorders.  It  is  most  com- 
monly seen  after  forty  years  of  age,  but  may  begin  earlier  ; 
it  is  usually  brought  on  by  some  condition  which  lowers  or  dis- 
turbs the  health ;  it  may  be  associated  with  the  occurrence  of  the 
menopause  or  from  excessive  mental  anxiety.  The  functions 
become  disordered  in  consequence  of  this  disturbance  of  their 
nerve  innervation  ;  disorders  of  digestion  arise,  food  is  digested 
or  assimilated  slowly  ;  there  are  neuralgic-like  pains  and  other 
abnormal  sensations  in  the  stomach  and  intestines  ;  less  and 
less  food  is  taken,  it  causes  distress.  Constipation  arises,  sleep 
is  imperfect  ;  soon  the  ideas  become  painful  and  anxious  ;  they 
fix  their  attention  on  these  morbid  sensations  and  the  functions 
of  the  body  ;  the  abdomen  and  genital  apparatus  are  frequently 


INSANITY.  183 

the  parts  upon  which  their  attention  centres  ;  they  exaggerate 
all  their  conditions.  They  express  fear  that  they  are  suffering 
from  some  serious  disease  of  the  stomach ;  it  is  cancerous,  or 
its  secretions  are  all  dried  up,  or  it  is  displaced  so  that  the  food 
cannot  get  into  it.  Under  these  delusions  they  eat  less  and  less, 
or  they  think  the  intestines  are  closed,  or  they  cannot  swallow, 
or  their  bodies  are  wasting,  and  their  brains  are  undergoing  a 
process  of  decay.  Their  friends  and  physicians  have  no  knowl- 
edge of  the  gravity  of  their  condition,  and  here  one  finds  often 
a  tinge  of  egotism  or  exalted  ideas  of  their  superior  knowledge  ; 
they  know  their  true  condition,  no  one  else  does,  or  they  an- 
nounce that  there  never  was  a  case  like  theirs.  Some  of  them 
are  fond  of  recounting  their  morbid  sensations  and  ideas  over 
and  over  again,  for  they  can  think  of  nothing  else  ;  while  others 
remain  passive,  resist  every  effort  to  induce  them  to  eat  or  dress ; 
they  may  scream  or  become  agitated  if  urged  too  closely  to  eat. 
Often  if  food  is  left  within  their  reach  they  will  eat  it,  at  the 
same  time  protesting  their  inability  to  take  food.  They  will 
often  resist  the  calls  of  nature,  protesting  that  their  bowels  are 
closed,  until,  unable  to  resist  longer,  they  pass  their  excrements 
in  their  clothing.  They  are  never  able  to  correct  their  erroneous 
impressions  and  ideas,  their  will-power  is  weakened,  but  on  sub- 
jects unconnected  with  their  physical  condition  they  reason  as 
correctly  and  keenly  as  formerly  ;  others  are  passive,  do  not 
wish  to  consult  a  physician,  they  are  hopelessly  diseased  and 
must  soon  die.  Their  moral  nature  is  joerverted,  they  make 
every  effort  apparently  to  convince  their  family  of  the  correct- 
ness of  their  views,  render  themselves  disagreeable  and  exacting, 
pour  out  all  manner  of  forebodings  and  predictions  of  a  dis- 
agreeable character,  make  pretence  of  great  suffering  apparently 
to  give  anxiety  to  their  friends. 

It  is  always  a  chronic  condition  ;  it  begins  slowly  and  pro- 
gresses slowly  ;  it  may  have  remissions  ;  later,  it  becomes  con- 
firmed, or  it  may  have  added  to  it  a  true  melancholia,  or  have 
engrafted  upon  it  a  systematized  delirium. 

Prognosis.    Is  not  favorable  in  these  cases. 

Treatment.  Efforts  should  be  made  to  build  up  the  nutrition 
by  enforced  feeding  ;  tonics  can  be  given,  and  allay  if  possible  the 


184  NERVOUS    DISEASES    AND    INSANITY. 

morbid  irritability.    Morphia  is  of  some  service  here.     Often, 
medication  is  useless. 

General  Paralysis  of  the  Insane. 

(Progressive  Paresis,  Dementia  Paralytica.) 

This  is  a  chronic  disease  of  the  brain,  characterized  by  marked 
mental  enfeeblement,  with  grandiose,  hypochondriacal,  or  me- 
lancholic delirium. 

Etiology.  This  appears  not  to  be  clearly  determined ;  it  is  very 
frequently  seen  in  persons  of  neuropathic  inheritance  ;  excesses 
of  all  kinds,  in  alcoholic  drink,  venery,  excessive  mental  strain, 
and  anxieties  in  business,  late  hours,  and  excessive  eating.  The 
changes  brought  about  by  syphilitic  poison  are  undoubtedly  a 
frequent  cause. 

Symptoms.  As  prodromal  symptoms,  found  in  many  cases,  are 
marked  changes  in  the  disposition  and  character  ;  they  become 
irritable  and  fault-finding,  especially  at  home,  quarrel  with  their 
wives  and  children  without  cause ;  neglect  their  work,  make  mis- 
takes in  their  business,  are  careless ;  formerly  of  exemplary  char- 
acter, they  now  begin  to  drink  freely,  are  over-active,  but  in  a 
careless,  disorderly  manner,  going  from  one  subject  to  the  other, 
without  the  least  effort  to  accomplish  any  thing  they  undertake  ; 
they  may  associate  with  fast  women,  upon  whom  they  spend 
large  sums  of  money.  They  complain  of  fulness  and  pain  in 
the  head,  vertigo,  and  insomnia.  After  this  prodromal  stage  the 
delirium  may  be  extravagant,  hypochondriacal,  or  melancholic  ; 
or  there  may  be  a  passive,  self-satistied  state.  There  may  be  a 
sudden  or  gradual  development  of  grandiose  ideas  ;  they  become 
very  active,  sanguine  to  the  extreme  about  their  business  pros- 
pects, anticipate  the  making  of  large  sums  of  money  ;  talk 
incessantlj?^  of  business  enterprises,  one  after  the  other,  and 
usually  of  immense  extent,  requiring  for  their  development 
very  large  sums  of  money.  The  absurdity  of  these  plans,  and 
the  bringing  in  of  collateral  plans  of  the  most  ridiculous  kind 
are  evidence  of  their  mental  weakness ;  the  weakened  memory 
is  marked  by  their  forgetting  the  detail  of  their  plan  as  first 


INSANITY.  18.3 

stated  ;  or  they  may,  as  one  of  my  patients  did  (who  was  a 
book-keeper),  start  unbidden  to  establish  a  branch- house  in  a 
neio-hboring  city,  where  he  became   confused,  lost  himself  in 
the  street,  was  taken  up  by  the  police  ;  on  his  way  back  to  Xew 
York  he  lost  his  way  in  Jersey  City  and  wandered  about  for 
many  hours.     Or  they  are  suddenly  plunged  into  a  maniacal 
state,  talking  incessantly,  passing  from  one  extravagant  state- 
ment to  another  without  any  connection  ;  are  in  constant  phy- 
sical activity  ;  there  may  be  a  decided  mental  confusion ;  tlu-y 
may  tear  and  break  things  about  them.     Others  are  moderately 
quiet  and  happy  in  their  ideas  of  wealth ;  if  they  are  unrestrained, 
they  spend  large  sums  of  money,  buy  horses  and  carriages,  gloves, 
umbrellas,  in  large  numbers,  or  spend  their  money  on  useless 
trifles  ;  or  in  their  activity  they  may  paint  their  houses  inside 
with  whitewash,  or  in  the  most  fantastic  colors.      They  may 
pick  up  pieces  of  coal,  w^ood,   stones,  and  rubbish,  say  they 
are  diamonds,  gold,  or  valuable  articles,  and  put  them  away 
carefully.     The  sexual  desire  is  often  much  exaggerated  at  this 
period.     They  wander  from  one  extravagant  idea  and  act  to 
another  ;  their  variety  is  innumerable.    Instead  of  the  ambitious 
delirium  there  may  be  hypochondriacal  ideas,  or  melancholic  ; 
they  are  depressed,  say  their  teeth  are  lost,  something  is  wrong 
with  their  eyes,  arms,  or  mouth  ;  complain  of  pain  in  various 
parts  of  the  body  ;  show  what  they  take  to  be  changes  in  their 
skin  and  hands  ;  are  very  emotional ;  cry  without  cause.  They 
are  often  conscious  of  their  condition.      There  may  also  be  a 
mild  delirium  of  persecution  ;  they  think  people  are  following 
them,  or  watching  them.      This  deUrium  may  continue  until 
dementia  is  extreme,  or  it  may  be  replaced  by  extravagant 
ideas   or  there  may  be  mild  ambitious  ideas  associated  with  it. 
Another  form  is  the  delirium  of  satisfaction  ;  the  person  feels 
perfectly  well ;  never  was  better  in  his  life  ;  is  satisfied  and  con- 
tented even  with  the  plainest  food  and  housing  ;  is  quiet,  gives 
expression  to  no  ideas  or  wants.      The  defect  in  memory  in- 
creases ;  they  lose  themselves,  forget  the  ordinary  occurrences 
in  their  daily  life. 

The  physical  symptoms  which  often  appear  early  are  difficulty 
in  speech,  it  is  thick  and  hesitating  ;  they  are  unable  to  pro- 


186  NERVOUS    DISEASES    AND    INSANITY. 

nounce  words  distinctly  ;  this  is  much  greater  if  the  person  is 
agitated  or  angry  ;  the  lips  and  facial  muscles  tremble.  The 
pupils  are  contracted  or  irregular,  or  one  is  larger  than  the 
other  ;  their  reaction  to  light  may  be  diminished  or  lost.  There 
may  occur  at  any  time  during  the  course  of  the  disease  epilepti- 
form and  apoplectiform  seizures.  The  epileptiform  attacks  may 
begin  with  localized  twitchings  of  the  muscles  of  the  face  or  one 
hand,  and  gradually  extend  into  a  generalized  convulsion  ; 
with  all  the  features  of  epilepsy— during  which  the  temperature 
runs  very  high.  There  may  be  a  series  of  these  convulsions 
similar  to  those  found  in  status  epilepticus  ;  during  these  attacks 
the  person  may  die  ;  or  the  convulsions  may  cease,  leaving  him 
ver}^  stupid,  and  perhaps  paralyzed  on  one  side.  This  stupor 
and  paralysis  usually  pass  avva}^ ;  the  person  is  always  worse 
after  these  attacks  ;  it  can  be  observed  that  he  is  weaker  and 
more  feeble  mentally  ;  it  is  possible  to  have  a  lasting  hemiplegia 
in  these  cases.  Apoplectiform  seizures  occur  in  which  there  are 
no  convulsions  ;  they  suddenly  become  rigid,  stupid,  pass  urine 
on  themselves  ;  in  a  short  time  they  recover,  but  are  stupid  and 
dull,  with  more  or  less  marked  hemiplegia,  which  gradually  dis- 
appears. The  tendon  reflex  may  be  present,  absent,  or  ex- 
aggerated. As  the  disease  progresses,  they  become  more  and 
more  feeble,  mentally  and  physically.  The  urine  may  dribble 
away.  They  eat  voraciously  whatever  is  set  before  them  ;  taste 
is  evidently  very  much  diminished  ;  they  are  at  this  stage  in 
danger  of  choking  themselves  by  trying  to  swallow  too  large 
pieces  of  food.  They  may  grow  very  stout,  exceptionally  thin  and 
cadaveric.  Trophic  disorders  appear.  The  bones  may  undergo 
changes  similar  to  that  found  in  locomotor  ataxia.  Ulcerations 
of  the  skin  and  paralytic  oedema  are  present.  If  they  are  not 
cut  off  by  convulsions  the  mental  enfeeblement  becomes  extreme  ; 
physically,  they  become  too  feeble  to  move  about,  and  are  con- 
sequently confined  to  bed  ;  diarrhoea,  extensive  bed-sores,  and 
ulcerations  of  the  soft  parts  of  the  heel  and  toes  occur,  and 
they  die  of  exhaustion  or  diarrhoea. 

At  any  time  during  the  early  course  of  the  disease  there  may 
be  an  entire  subsidence  of  the  delirium,  and  disappearance  of 
the  physical  symptoms  ;  the  person  is  apparently  recovered  ;  he 


INSANITY.  187 

expresses  no  longer  his  extravagant  ideas,  behaves  rationally, 
and  returns  to  his  business,  which  if  comparatively  simple  he 
may  perform  without  difficulty.  This  subsidence  of  the  symp- 
toms is  known  as  a  "  remission  ;"  it  may  last  from  a  few  months 
to  one  year,  when  the  person  again  presents  all  the  physical  and 
mental  symptoms  as  at  the  beginning,  and  the  disease  runs  its 
course  to  death. 

General  paralysis  occurs  in  women,  but  it  is  much  less  freque^nt ; 
in  my  experience  it  occurs  between  30  and  45  years  of  age  ;  it  has 
evidently  the  same  causes  as  in  men.  The  marked  delirium  of 
extravagance  is  seen  among  women,  but  very  much  less  frequently 
than  in  men,  and  their  ideas  are  of  diamonds,  dresses,  their 
personal  appearance,  or  the  number  of  their  children  ;  as  a  rule 
the  delirium  is  of  a  quieter  kind  ;  they  are  satislied  ;  occasionally 
they  may  express  an  extravagant  idea,  it  is  then  usually  in  regard 
to  dress  or  personal  appearance  ;  a  w^oman  suddenly  puts  out 
her  foot  and  asks  if  it  is  not  a  pretty  foot,  or  she  picks  up  the  skirt 
of  her  dress  and  asks  if  her  underskirt  is  not  beautiful.  They 
may  have  the  hypochondriacal  and  melancholic  ideas.  The 
disease  comes  on  and  progresses  more  slowly  than  it  does  in 
men.     They  may  have  all  the  other  symptoms. 

Prognosis.  Is  unfavorable,  the  duration  varies ;  they  may 
live  two,  three,  or  four  years,  exceptionally  longer. 

Pathological  Anatomy.  Marked  thickening  of  the  pia  mater 
with  whitish  streaks,  especially  along  the  vessels  ;  the  pia  is  ad- 
herent in  places  to  the  cortex  ;  the  vessels  are  tortuous  and  dis- 
tended ;  the  changes  are  most  marked  over  the  frontal  lobes  and 
the  convolutions  about  the  fissure  of  Rolando  ;  there  is  more  or 
less  atrophy  of  the  convolutions,  with  spots  in  which  the  atrophy 
is  more  extensive  ;  here  there  may  be  found  considerable  cedema 
of  the  pia  mater.  The  occipital  lobes  are  usually  healthy.  The 
ventricles  may  be  distended  with  fluid ;  the  ependyma  is 
granular. 

Histologically,  the  vessels  are  tortuous  and  enlarged.  With 
aneurismal  dilatations,  the  nuclei  in  their  walls  are  increased^ 
especially  at  their  bifurcations,  with  fatty  and  colloid  degenera- 
tions of  their  walls.  The  perivascular  spaces  are  distended  and 
contain  leucocytes  and  pigment  granules.     There  is   marked 


188  NERVOUS    DISEASES    AND    INSANITY. 

evidence  of  liyperseiiiia  in  the  deep  layers  of  the  cortex  and 
basal  ganglia.  The  nerve-fibres  have  disappeared,  and  there  is 
an  increase  in  ihe  neuroglia  with  a  profusion  of  spider-cells. 
The  nerve-cells  have  undergone  all  degrees  of  fatty  and  pig- 
mentary degeneration.  In  the  spinal  cord  there  is  more  or  less 
extensive  change  ;  sclerosis  in  the  posterior  columns  ;  degenera- 
tion in  the  lateral  columns,  or  more  diffused  lesions.  This  con- 
dition is  often  spoken  of  as  chronic  diffuse  meningo-encephalitis, 
implying  an  inflammatory  origin.  Opinion  differs  on  this  point. 
Treatment.  There  is  no  treatment  which  cures  this  disease. 
The  excitement  is  lessened  by  the  use  of  ergot  and  bromide  of 
soda  or  potassa.  In  those  cases  where  there  is  a  clear  history  of 
syj^hilis,  iodide  of  potassa  in  increasing  doses,  as  is  given  in 
syphilitic  nervous  diseases,  produces  no  effect  whatever  in  this 
disease.  Counter-irritation  of  the  scalp  with  tartar  emetic 
ointment  gives  some  temporary  relief  to  the  headache  and  ful- 
ness, but  it  is  a  very  painful  apphcation.  Yery  recently  tre- 
phining has  been  tried,  but  it  is  not  at  all  likely  that  it  will 
be  of  much  service,  and  the  indications  for  its  use  are  ex- 
ceedingly vague.  Quite  a  large  proportion  of  these  cases  have 
to  be  removed  to  asylums,  others  are  quiet  and  are  kept  at 
home. 

Imbecility  and  Idiocy. 

An  arrest  of  cerebral  development,  either  in  utero  or  after 
birth,  and  in  consequence,  entire  absence  or  enfeeblement  of  the 
mental  processes. 

These  two  names  indicate  the  degree  of  mental  weakness  ;  it 
is  greatest  in  the  idiot  ;  the  extent  of  mental  weakness  varies 
very  much. 

Etiology.  Hereditary  ;  plays  an  important  and  large  part  in 
its  causation;  consanguineous  marriages;  scrofula;  anything 
which  very  materially  affects  the  nutrition  and  general  health 
of  the  mother  may  cause  it ;  injuries,  great  anxiety,  or  fright 
may  also  be  causes.  Drunkenness  in  the  parents.  It  may  be 
the  result  of  some  cerebral  disease  coming  on  in  the  first  period 


INSANITY.  189 

of  lif(i,  or  injuries  at  that  age  ;  falls  may  cause  it,  by  the  injury 
done  to  the  brain.     (See  Spastic  Hemiplegia  in  Children.) 

Symptoms.  Numerous  classifications  have  been  made  of  idiots 
and  imbeciles.  Ireland  described  the  genetous  form  which  is  the 
result  of  intrauterine  disturbances;  these  children  are  defective 
when  they  are  born  ;  he  thinks  the  enlarged  glands,  abscesses, 
skin  eruptions,  etc.,  from  which  they  suffer,  point  to  scrofula  as 
a  cause.  Two-thirds  (|)  of  them  he  says  die  of  consumption  ; 
physically,  they  are  feeble,  with  impaired  circulation,  low 
temperature,  cold  extremities,  and  defective  sensibilities. 
Trophic  disturbances  are  easily  set  up  ;  their  secretions  are  de- 
fective and  abnormal,  with  unpleasant  odor  ;  the  heart  is  weak 
with  defective  valves,  and  often  an  open  foramen  ovale.  They 
have  the  vaulted  palate,  the  jaw  protrudes,  and  the  teeth  project. 
They  are  dwarfish,  and  retain  an  infantile  appearance  ;  they 
are  liable  to  deformities  of  the  fingers  and  toes,  coloboma  and 
hernia,  and  the  testicles  are  occasionally  wanting. 

Cretinoid  idiots  are  not  common  ;  they  are  short,  with  broad 
features,  wide  distance  between  the  eyes,  mouth  large,  thick, 
lips  kept  open,  hands  and  feet  thick  and  broad. 

Microcephalic  idiots,  in  which  there  is  lack  of  development  of 
all  the  cerebrum  or  only  portions  of  it,  or  parts  may  be  entirely 
absent ;  the  deficiency  is  generally  in  a  diminution  in  the  size  of 
the  hemispheres.  The  head  is  narrow  and  tapering  toward  the 
top,  the  nerves,  basal  ganglia,  and  spinal  cord  are  usually  better 
developed  than  the  hemispheres.  The  cerebellum  relatively 
larger  than  in  normal  brains. 

The  further  divisions  are  eclampsic,  epileptic,  hydrocephalic, 
paralytic,  traumatic,  inflammatory,  etc.  It  will  be  unnecessary 
to  go  into  a  detailed  explanation  of  these  varieties.  In  idiots 
there  is  scarcely  any  mental  life  ;  they  eat  and  drink  when  it  is 
given  them  regardless  of  what  it  is  ;  they  neither  speak  nor  have 
consciousness  ;  they  manifest  such  pleasure  and  pain  as  they  are 
capable  of  by  inarticulate  sounds  or  screams  with  disorderly 
movements ;  they  are  incapable  of  education.  Some  idiots  may 
recognize  persons  they  frequently  see ;  they  have  no  memory  or 
idea  of  time.  Their  appearance  is  usually  hideous;  they  eat 
ravenously  what  is  set  before  them  ;  they  often  drink  the  most 


190  NERVOUS    DISEASES    AND    INSANITY. 

disgusting  and  disagreeably  tasting  fluids  ;  they  do  not  appear 
to  suffer  pain  as  normal  individuals  ;  they  do  not  notice  bruises 
and  cuts,  and  often  show  no  evidence  of  extreme  changes  of 
temperature. 

Imbecility  is  a  less  profound  arrest  of  the  mental  processes ; 
it  usually  occurs  as  the  result  of  some  disease  process,  if  not  at 
birth  in  the  first  three  (3)  or  four  (4)  years  of  life,  but  it  may 
also  occur  before  birth  as  some  defect  in  development.  Imbeciles 
vary  very  much  as  to  their  behavior,  facial  expression,  move- 
ments, etc.,  and  their  abihty  to  learn.  They  are  susceptible  of 
more  or  less  education.  Those  who  suffer  epilepsy  as  a  com- 
plication are  less  favorable  in  this  respect.  The  degree  of  mental 
activity  varies  ;  many  make  great  efforts  to  learn  to  walk  and 
what  is  taught  them.  They  often  have  great  difficulty  in  learn- 
ing numbers.  If  they  are  slow  in  learning  to  walk,  they  will  be 
slow  in  learning  to  speak  and  in  the  acquiring  of  other  knowl- 
edge. The  ability  to  speak  depends  upon  the  range  of  idens 
which  the  child  is  capable  of.  Some  idiots  never  speak ;  they 
appear  to  be  aphasic  ;  they  often  show  an  aptitude  for  music. 

These  imbeciles  and  idiots  may  have,  besides  the  epilepsy 
alluded  to,  paralysis,  hemiplegic,  or  paraplegic  in  type  (see 
Spastic  Hemiplegia  in  Children),  as  the  result  of  atrophies  of 
the  brain.  Sclerosis  disseminated  may  be  found,  and  various 
abnormalities  of  the  cerebral  conformation. 

For  further  information  on  this  subject  consult  Ireland,  Idiocy 
and  Imbecility  ;  E.  Seguin,  Idiocy  ;  the  reports  of  Dr.  Kerlin, 
Dr.  Wilbur,  etc. 

BibliograjjJii/. — Sankey,  Lectures  on  Mental  Diseases. — Clous- 
ton,  Mental  Diseases. — Hammond,  Treatise  on  Insanity. — 
Greisinger,  Mental  Disease,  Translation.  — Spitzka,  Insanity,  2d 
edition. — Bevan  Lewis,  Text-Book  of  Mental  Disease. — Mickel, 
General  Paralysis  of  the  Insane.  — Krafft  Ebing,  Lehrbuch  der 
Psychiatric. — Mendal,  Die  progressiv^e  Paralyse  der  Irren. — 
Yoisin,  Paralysie  Generale  des  Alieues.  — The  Journal  of  Mental 
Science. — The  American  Journal  of  Insanity. 


INDEX. 


A  BSCESSof  brain,  106 
j\     Acromeg'aly,  89 
Acute  ascending  paralysis,  56 
Acute  infectious  multiple  Tieuritis, 

26 
Acute  meningitis  cerebral,  96 
Acute  myelitis  of  the  anterior  borns, 

58,  60 
Acute  poliomyelitis  anterior,  58,  60 
Acute  spinal  meningitis,  51 
Acute  spinal  paralysis  of  the  adult, 

60 
Agraphia,  119 
Alcoholic  insanity,  174 
Alcoholic  paralysis,  22 
Amyotrophic  lateral  sclerosis,  65 
Ansesthesia  is  in  the  distribution  of 

injured  nerves,  18 
Angina  pectoris,  141 
Aphasia,  119 
Apoplectiform  seizures  in  locomotor 

ataxia,  74 
Apraxia,  119 

Argylle  Robertson  pupil,  72 
Arthropathies  in  locomotor  ataxia, 

74 
Ataxic  paraplegia,  84 


BASE  of  brain,  lesions  of,  132 
Bell's  palsy,  30 
Brachial  plexus,  paralysis  of,  37 
Brain,  abscess  of,  106 


nAUSALGTA,  17 
\J    Cephalalgia,  138 
Cerebellum,  lesions  of,  130 
Cerebral  glosso-labio  laryngeal  par- 
alysis, 123 
Cerebral  hemorrhage,  99 
Cerebral  localization,  117 
Cerebral  meningitis,  acute,  96 


Cerebro-spiual  sclerosis,  107 
Cervico-brachial  neuralgia,  48 
Cervico-occipital  neuralgia,  47 
Choked  disc,  104 
Chorea,  134 

hereditary,  133 
Chronic  hydrocephalus,  OS 
Chronic    myelitis    of   the    anteiior 

horns,  62 
Circular  insanity,  170 
Circumflex  nerve,  paralysis  of,  36 
Combined  sclerosis,  84 
Compression  mj^el'itis,  54 
Conceptions,  imperative,  177 
Contractures  in  locomotor  ataxia,  74 
"  Crises"  in  locomotor  ataxia,  74 
Crus  cerebri,  lesions  of,  139 


DEGENERATIVE  insanities,  164 
Delusions,  154 
Dementia,  paralytica,  184 
senile,  162 
terminal,  163 
Digiti  mortui,  150 

Disseminated  cerebro-spinal  sclero- 
sis, 107 
Dyschromatopsie,  125 
Dystrophies,  muscular,  85 


EMBOLISM,  101 
Endarteritis,  101 
Epilepsy,  109 
Epileptic  insanity,  172 
Erb's  paralysis,  37 
Erythemomegalalgia,  151 
Exophthalmic  goitre,  140 


FACIAL  atrophy,  142 
Facial  paralysis,  peripheral,  30 
Facial  spasm,  unilateral,  42  " 

(191) 


192 


INDEX 


Fifth-nerve  neuralgia,  45 
Friedreich's  disease,  80 


GENERAL  paralysis  of  the  insane, 
184 
Glosso-labio  laryngeal  paralysis,  ()3, 

65 
cerebral,  123 
Goitre,  exophthalmic,  140 
Graves's  disease,  140 


HALLUCINATIONS,  154 
Headache,  188 
Hemianesthesia,  125 
Hemianopsia,  120 
Hemicrania,  46 
Heraiparetic   attacks  In  locomotor 

ataxia,  74 
Hemiplegia,  spastic,  114 
Hemorrhage,  cerebral,  99 
Hereditary  ataxia,  80 
Hereditary  chorea,  135 
Herpes  zoster,  49 
Hydrocephalus,  chronic,  98 
Hypochondria,  182 
Hysteria,  143 
Hysterical  insanity,  169 


IDIOCY,  188 
.1     Illusions,  154 
Imbecility,  188 
Imperative  conceptions,  177 
Infantile  spinal  paralysis,  58 
Infectious  neuritis,  26 
Injuries  of  nerves,  17 
Insanity,  alcoholic,  174 

circular,  170 

epileptic,  172 

hysterical,  169 

periodic,  169 
Intracranial  tumors,  103 


LANDRY'S  paralysis,  56 
Larj^ngeal  paralysis,  87 
Lateral  amyotrophic  sclerosis,  65 
Lateral  columns,  sclerosis  of,  70 
Lead  paralysis,  25 
Lepto-meningitis,  spinal,  51 
infantum,  96 
with  pus,  96 
Lesions  of  base  of  brain,  132 


Lesions — 

of  centrum  ovale,  122 
of  cerebellum,  130 
of  corpora    quadrigeminal    re- 
gion, 125 
of  corpus  striatum  and  lenticu- 
lar nucleus,  122 
of  crus  cerebri,  129 
of  internal  capsule,  125 
of  posterior  part  internal  cap- 
sule, 125 
of  thalamus,  125 
Localization,  cerebral,  117 

of  functions  in  spinal  segments, 

94 
of  lesions  in  spinal  cord,  91 
Locomotor  ataxia,  72 
Lumbar  plexus,  paralysis  of,  37 


ANIA,  160 
periodic,  169 
Median  nerve,  paralysis  of,  35 
Melancholia,  155 
periodic,  170 
Meningitis,  cerebral,  acute,  96 
purulent,  96 
spinal,  acute,  51 
tubercular,  97 
Mental      disorders     in     locomotor 

ataxia,  76 
Migraine,  46 
Morvan's  disease,  26 
Muscular    atrophy,    in     locomotor 
ataxia,  74 
peroneal  form,  64 
progressive,  62 
Muscular  dystrophies,  85 
Muscular  pseudo-hypertrophy,  85 
Musculo-spiral  nerve,  paralysis  of, 

36 
Myelitis,  52 

compression,  54 
of  anterior  horns,  acute,  58 
of  anterior  horns,  chronic,  62 
Mysophobia,  179 


NAILS,  trophic  disorders  of,  18 
Nerve,  abducens,  paralysis  of, 
30 
Nerve,  circumflex,  paralysis  of,  36 
median,  paralysis  of,  35 
musculo-spiral,  paralysis  of,  36 
ocular-motor,  paralysis  of,  29 


INDEX. 


193 


Nerves — 

ulnar,  35 
Nerves,  injuries  of,  17 

trophic  disorders  in,  18 
Neuralg-ia  of  cervico-bracliial  nerve, 
48 

of  cervico-occipital  nerve,  47 

of  fifth  nerve,  45 

sciatic,  48 
Neurasthenia,  136 

Neuritis,  acute  infectious  multiple, 
26 

alcoholic,  2*3 

diphtheritic,  24 

from  lead  poisoning,  25 

multiple,  21 

peripheral,  20 


OBSTETRICAL  paralysis,  37 
Occlusion  of  vessels,  101 
Ophthalmoplegia,  104,  126 
Optic  neuritis,"  104 
Optic  radiations  of  Gratiolet,  lesions 
of,  125 


PARALYSIS,  acute  ascending,  56 
Paralysis  agitans,  111 

Paralysis,  alcoholic,  22 
diphtheritic,  24 
Erb's,  37 

in  caries  of  spine,  55 
in  fracture  of  spine,  55 
in  locomotor  ataxia,  74 
laryngeal  branches  of  vagus,  37 
lead,  25 

lumbar  plexus,  37 
obstetrical,  37  ' 
of  brachial  plexus,  37 
of  circumflex  nerve,  36 
of  facial  nerve,  peripheral,  30 
of  median  nerve,  35 
of  musculo-spiral  nerve,  36 
of  peripheral  nerves,  29 
of  third  and  sixth  nerves,  29 
of  ulnar,  35 

pseudo-hypertrophic,  85 
sacral  plexus,  37 

Paranoia,  165 

Paraplegia,  ataxic,  84 
spastic,  70 

Periarteritis,  100 

Periodic  mania,  169 

Periodic  melancholia,  170 
13 


Peroneal  form  of  progressive  mus- 
cular atrophy,  64 

Perverted  sexual  instincts,  180 

Pituitary  body,  tumors  in  neiglibfir- 
hood  of,  133 

Poliomyelitis  anterior,  acute,  58,  60 

Postero-lateral  spinal  sclerosis,  80 

Pott's  disease,  55 

Primary  lateral  sclerosis,  70 

Progressive  paresis,  184 

Progressive  muscular  atrophv,  62, 
64  1    ^.        » 

Pupil,  in  locomotor  ataxia,  72 
Purulent  meningitis,  96 


QUADRIGEMINAL  region, lesions 
of,  125 


D  AYNAUD'S  disease,  152 


O  ACRAL  plexus,  paralysis  of,  37 

O     Sciatica,  48 

Sclerosis,  cerebrospinal,  107 

combined,  84 

lateral  amyotrophic,  65 
columns,  70 
Senile  dementia,  162 
Sensory  aphasia,  119 
Seventh  nerve,  paralysis  of,  30 
Sexual  instincts,  perverted,  180 
Sick  headache,  46 
Sixth  nerve,  paralysis  of,  30 
Spasm,  40 

in   muscles  supplied  by  spinal 
accessory,  41 

splenius  capitis,  43 

unilateral  facial,  42 
Spastic  hemiplegia  in  children,  114 
Spastic  paraplegia,  70 
Spastic  spinal  paralysis,  70 
Spinal  cord,  localization  of  lesions 

in,  91 
Spinal  meningitis,  acute,  51 

paralysis,  infantile,  58 

paralysis  of  the  adult,  60 
Spinal     segments,    localization    of 

functions  in,  94 
Spine,  caries  of,  55 

fracture  of,  55 
Subcortical  lesions,  122 
Syringo  myelia,  67 


194 


INDEX. 


TABES  dorsalis,  70 
Terminal  dementia,  163 
Tetanoid  paraplegia,  70 
Thalamus,  lesions  of,  125 
Third  nerve,  paralysis  of,  29 
Thomsen's  disease,  44 
Thrombosis,  101 
Trifacial  neuralgia,  45 
Trophic    disorders,    in    locomotor 

ataxia,  75 
Tubercular  meningitis,  97 
Tumors,  in  neighborhood  of  pitui- 
tary body, 133 
intracranial,  103 
intraspinal,  55 


ULNAR  nerve,  paralysis  of,  35 
Unilateral  facial  atrophy,  142 
Unilateral  facial  spasm,  42 


VAGUS,    paralysis    of    laryngeal 
branches,  37 
Vaso-motor  neurosis,  149 


WORD  blindness,  119 
Word  deafness,  119 
Writer's  cramp,  43 


7OSTER,  herpes,  49 


CATALOGUE 


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Essentials  of  Anatomy  and  Manual  of  Practical 

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By  CHARLES  B.  NANCREDE,  M.D., 

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and  Dissector— this  is  a  good  dissector's  manual,  with  clear  type  and  hand- 
some cuts.    The  colored  plates  are  especially  commendable. 

The  Southern  Practitioner,  Nashville,  Tenn.,  September,  1890.— Nancrede's 
Anatomy  and  Dissector— truly  a  "  Vade  Meeum,"  a  "  multum  in  parvo."  The 
illustrations  are  marvels  of  beauty  and  clearness  of  illustration. 

7 


IN  PREPARATION. 


DISEASES  OF  THE  EYE. 

BY 

G.  E.  DE  SCHWEINITZ,  M.D., 

Ophthalmic  Surgeon  to  Children's  Hospital  and  to  the  Philadelphia  Hospital  j 
Ophthalmologist  to  the  Orthopaedic  Hospital  and  Infirmary  for  Ner- 
vous Diseases ;   Lecturer  on  Medical   Ophthalmoscopy, 
University  of  Pennsylvania,  etc. 


A  HAND-BOOK  OF  OPHTHALMIC  PRACTICE, 

Especiall}^  useful  to  the  student  who  has  had  neither  time 
nor  inclination  to  study  the  numerous  able  hut  more  volu- 
minous text-books. 


The  object  of  this  manual  is  to  present  to  the  student  who  is  be- 
ginning work  in  the  field  of  ophthalmology  a  plain  description  of 
the  optical  defects  and  diseases  of  the  eye.  To  this  end  special 
attention  has  been  paid  to  the  clinical  side  of  the  question  ;  and  the 
methods  of  examination,  the  symptomatology  leading  to  a  diagnosis, 
and  the  treatment  of  the  various  ocular  defects  have  been  brought 
into  special  prominence.  Anatomy,  physiology,  and  pathological 
histology,  except  in  so  far  as  they  serve  the  purpose  just  stated, 
have  been  omitted.  The  sections  devoted  to  optical  principles  and 
the  normal  and  abnormal  refraction  of  the  eye  in  large  portion  have 
been  written  by  Dr.  James  Wallace,  Chief  of  the  Eye  Dispensary  of 
the  University  Hospital.  The  chapter  devoted  to  the  application 
of  the  shadow-test  has  been  prepared  by  Dr.  Edward  Jackson.  The 
book  will  be  suitably  illustrated  by  a  number  of  wood-cuts,  many  of 
them  from  eases  in  the  practice  of  the  author,  in  addition  to  which 
there  will  be  several  chromo-lithographs. 


IN  PREPARATION. 


DISEASES  OF  WOMEN. 

By  henry  J.  GARRIGUES,  A.M.,  M.D., 

Professor  of  Obstetrics  in  the  New  York  Post-Graduate  Medical  Schf>ol  and 
Hospital  ;  Gynaecologist  to  St.  Mark's  Hospital  in  New  York  City  ;  Gynae- 
cologist to  tile  German  Dispensary  in  the  City  of  New  York  ;  Con- 
sulting Obstetrician  to  the  New  York  Infant  Asylum;  Obstetric 
Surgeon  to  the  New  York  Maternity  Hospital ;   Fellow  of 
the  American  Gynaecological  Society  ;   Fellow  of  the 
New  York  Academy  of  Medicine  ;   President  of  the 
German  Medical  Society  of  the  City  of  New 
York,  etc.  etc. 

It  is  the  intention  of  the  writer  to  provide  a  practical  manual  on 
Gynsecology,  for  the  use  of  students  and  practitioners,  in  as  concise  a 
manner  as  is  compatible  with  clearness. 


Syllabus  of  Obstetrical  Lectures 

In  the  Medical  Department,  University  of  Pennsylvania. 

By  RICHARD  C.  NORRIS,  A.M.,  M.D., 

Demonstrator  on  Obstetrics  in  the  University  of  Pennsylvania. 


Price,  Oloth,  Interleaved  for  Notes  .  .  .  $2.00  Net. 

The  New  York  Medical  Record  of  April  19,  1890,  referring  to  this 
hook,  says  :  "This  modest  little  work  is  so  far  superior  to  others  on 
the  same  subject  that  we  take  pleasure  in  calling  attention  briefly  to 
its  excellent  features.  Small  as  it  is,  it  covers  the  subject  thoroughly, 
and  will  prove  invaluable  to  both  the  student  and  the  practitioner  as 
a  means  of  fixing  in  a  clear  and  concise  form  the  knowledge  derived 
from  a  perusal  of  the  larger  text-books.  The  author  deserves  great 
credit  for  the  manner  in  which  he  has  performed  his  work.  He  has 
introduced  a  number  of  valuable  hints  which  would  only  occur  to  one 
who  was  himself  an  experienced  teacher  of  obstetrics.  The  subject- 
matter  is  clear,  forcible,  and  modern.  We  are  especially  pleased  with 
the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of 
the  child,  etc.  The  paragraphs  on  antiseptics  are  admirable  ;  there 
is  no  doubtful  tone  in  the  directions  given.  No  details  are  regarded 
as  unimportant  ;  no  minor  matters  omitted.  We  venture  to  say  that 
even  the  old  practitioner  will  find  useful  hints  in  this  direction  which 
he  cannot  afford  to  depise." 

9 


READY  SHORTLY. 


SAUNDERS' 

Pocket  Medical  Formalary. 

BY 

WILLIAM  M.  POWELL,  M.D., 

Attending  Physician  to  the  Mercer  House  for  Invalid  Women,  at  Atlantic 

City,  N.  J.  ;  Late  Physician  to  the  Clinic  for  the  Diseases  of  Children 

in  the  Hospital  of  the  University  of  Pennsylvania  and  St.  Clement's 

Hospital ;  Instructor  in  Physical  Diagnosis  in  the  Medical 

Department  of  the  University  of   Pennsylvania,  and 

Chief  of  the  Medical  Clinic  of  the  Philadelphia 

Polyclinic. 


Containing  about  2000  Formulae,  selected  from  several 
hundreds  of  the  best- known  authorities. 


A  concise,  clear,  and  correct  record  of  the  many 
hundreds  of  famous  formulae  which  are  found  scattered 
through  th^,  works  of  the 

Most  Jiiininent  Physicians  and  Surgeons 

of  the  world.;  pa,rticularly  helpful  to  the  student  and 
young  practitioner,  as  it  gives  him  a  taste  for  writing  his 
prescriptions  m  an  elegant  and  correct  manner,  thus  avoid- 
mg  incompatible  and  dangerous  prescriptions.  The  use 
of  this  work  is  to  be  recommended  even  to  the  older  prac- 
tioner,  as  through  it  he  becomes  acquainted  with  numerous 
formulae  which  are  not  found  in  the  text-books,  but  have 
Deen  collected  from  among  the 

Rising  Generation  of  the  Profession,  College  Professors,  and 

Hospital  Physicians  and  Surgeons. 

10 


NOW  BEADY. 


NEW  AND  REVISED  EDITIONS  OF 

SAUNDERS' 

lUESTION  COMPENDS. 

Arranged  in  duestion  and  Answer  Form. 

The  Latest,  Cheapest,  and  Best 

ILLUSTRATED  SERIES  OF  COMPENDS  EVER  ISSUED. 


THE  ADVANTAGES  OF  QUESTIONS  AND 
ANSWERS. — The  usefulness  of  arranging-  the  subjects  in 
the  form  of  Questions  and  Ansvrers  will  be  apparent, 
since  the  student,  in  reading  the  standard  works,  often  is  at 
a  loss  to  discover  the  important  points  to  be  remembered, 
and  is  equally  puzzled  when  he  attempts  to  formulate  ideas 
as  to  the  manner  in  which  the  Questions  could  be  put 
in  the  Examination- Room. 


These  small  works,  which  can  be  conveniently  carried  in  the  pocket, 
contain  in  a  condensed  form  the  teachings  of  the  most  popular 
text -books. 

The  authors  are  nearly  all  connected  with  the  various  colleges  as 
Demonstrators  or  Lecturers,  and  are  therefore  thoroughly  conver- 
sant, not  only  with  the  wants  of  the  average  student,  but  also  with 
the  points  that  are  absolutely  necessary  to  be  remembered  in 
the  Examination-Room.  These  books  are  constantly  in  the  hands 
of  their  authors  for  revision,  and  are  kept  well  up  to  the  times,  their 
fast  sale  allowing  them  to  be  almost  entirely  rev^ritten  "whenever 
necessary,  instead  of  having  to  wait  for  the  edition  to  be  sold,  as  is 
the  case  with  an  ordinary  text  book. 

11 


No.  1. 

ESSEITIALS  OF  PHYSIOLOGY. 

BY 

H.  A.  HARE,  M.D., 

Professor  of  Therapeutics  and  Materica  Medica  in  the  Jefferson  Medical  CoU 

lege  of  Philadelphia;  Physician  to  St.  Agnes'  Hospital  and  to  the 

Medical  Dispensary  of  the  Children's  Hospital ;  Laureate  of 

the  Koyal  Academy  of  Medicine  in  Belgium,  of  the 

Medical  Society  of  London,  etc. ;  Secretary 

of  the  Convention  for  tlie  Kevision  of 

the  Pharmacopoeia,  1890. 


NUMEROUS  ILLUSTRATIONS. 
Third  Edition,  Revised  and  Enlarg^ed. 


Price,  Cloth 


$1.00 ;   Interleaved  for  Notes 


$1.25. 


University  Medical  Magazine, 
October,  1888.— '*  Dr.  Hare  has 
admirably  succeeded  in  gather- 
ing together  a  series  of  Ques- 
tions which  are  clearlj  put  and 
tersely  answered." 

Pacific  Medical  Jnvrnal,  Octo- 
ber, 1889.—"  Hare's  Physiology 
contains  the  essences  of  its  sub- 
ject. No  better  book  has  ever 
been  produced,  and  every  stu- 
dent would  do  well  to  possess  a 
copy." 

Times  and  Register,  Philadel- 
phia, October  5,  1889.—"  In  the 
second  edition  of  Hare's  Physi- 
ology all  the  more  difficult  points 
of  the  study  of  the  nervous  sys- 
tem have  been  elucidated.  As 
the  work  now  appears  it  cannot 
fail  to  merit  the  appreciation  of 
Specimen  of  Illustrations.  the  overworked  student." 

Journal  of  the  American  Association,  November  23,  1889. — "  Hare's 
Physiology — an  excellent  work  ;  admirably  illustrated  ;  well  calcu- 
lated to  lighten  the  task  of  the  over-burdened  undergraduate." 

12 


No.  2. 

ESSENTIALS  OF  SUR&ERY. 

CONTAINING,  ALSO, 

Venereal  Diseases,  Surgical  Landmarks,  Minor  and  Operative  Sur- 
gery, and  a  Complete  Description,  together  with  full  Illustra- 
tions, of  the  Handkerchief  and  Roller  Bandage. 

By  EDWARD  MART^,  A.M.,  M.D., 

Clinical  Professor  of  Genito-Urinary  Diseases,  Instructor  in  Operative  Sur- 

gery,  and  Lecturer  on  Minor  Surgery,  University  of  Pennsylvania; 

Surgeon  to  the  Howard  Hospital ;  Assistant  Surgeon  to  tlie 

University  Hospital,  etc.  etc. 


PROFUSELY   LLLUSTRATED. 

FOURTH  EDITION. 
Considerably  enlarged  by  an  Appendix  containing  fall  directions 
and  prescriptions  for  tlie  preparation  of  tlie  various  mate- 
rials used  in  ANTISEPTIC  SURGERY  ;  also  sev- 
eral liundred  recipes  covering  the  medical 
treatment  of  surgical  affections. 
Price,  Cloth,  $i.oo.     Interleaved  for  Notes,  $1.25. 

Medical  and  Surgical  Reporter, 
February,  1889.  —  "  Martin's  Sur- 
gery contains  all  necessary  essen- 
tials of  modern  surgery  in  a  com- 
paratively small  space.  Its  style 
is  interesting  and  its  illustrations 
admirable." 

Umversity  Medical  Magazine, 
January,  1889.  —  "Dr.  Martin  has 
admirably  succeeded  in  selecting 
and  retaining  just  what  is  neces- 
sary for  purposes  of  examination, 
and  putting  it  in  most  excellent 
shape  for  reference  and  memor- 
izing." 

Kansas  City  Medical  Record. — 
"Martin's  Surgery. — This  admir- 
able compend  is  well  up  in  the 
most  advanced  ideas  of  modern 
surgery.'* 

13 


Specimen  of  Illustrations. 


No.  3. 

ESSENTIALS  OF  ANATOMY, 

Including  the  Anatomy  of  the  Viscera. 

By  CHARLES  B.  NANCREDE,  M.D., 

Prvjfessor  of  Surgery  and  Clinical  Surgery  in  t-he  University  of  Michigan, 

Ann  Arbor ;  Corresponding  Member  of  the  Royal  Academy  of 

Medicine,  Rome,  Italy  ;  Late  Surgeon  Jefferson 

Medical  College,  etc.  etc. 

ONE  HUNDRED  AND  FORTY  FINE  WOODCUTS 

THIRD  EDITION. 

Enlarged  by  an  Appendix  containing  over  Sixty  Illustrations  of 

the  Osteology  of  the  Human  Body. 

The  "wliole  based  upon  the  last  (eleventh)  edition  of 

GRAY'S  ANATOMY. 

Price,  Cloth,  $1.00.    Interleayed  for  Notes,  $1.25. 

America)!  Practitioner   and 
News,  February  16,  1889. 

"  Nancrede'ri  Anatomy. — 
For  self-quizzing  and  keep- 
ing fresh  in  mind  the 
knowledge  of  Anatomy 
gains  at  school,  it  wonld 
not  be  easy  to  speak  of  it 
in  terms  too  favorable." 

/Southern   Californian   Practi- 
tioner, January  18,  1889. 

"  Nancrede's  Anatomy. — 
Very  accurate  and  trust- 
worthy." 

American    Practitioner    and 

News,  Louisville,  Kentucky- 

"Nancrede's  Anatomy. — 

Truly  such   a  book    as  no 

student    can   afford   to    be 

without." 


Specimen  of  Illustrations. 


14 


No.  4. 

Essentials  of  Medical  Chemistry 

ORGANIC  AND  INORGANIC. 

CONTAINING,  ALSO, 

Questions  on  Medical  Physios,  Chemical  Physiology, 
Analytical  Processes,  Urinalysis,  and  Toxicology. 

BY 

LAWRENCE  WOLFF,  M.D  , 

Demonstrator  of  Chemistry,  Jefferson  Medical  College  ;  Visiting  Physician 

to  German  Hospital  of  Philadelphia  ;  Member  of  Philadelphia 

College  of  Pharmacy,  etc.  etc. 

SIXTH  THOUSAND. 


Price,  Cloth,  $1.00.     Interleaved  for  Notes,  $1.25. 


Cincinnati  Medical Nevjs,  January,  1889.  —  "  Wolff's  Chemistry.-  -A  little 
work  that  can  be  carried  in  the  pocket,  for  ready  reference  in  solving  difficult 
problems." 

St.  Joseph'' s  Medical  Herald,  March,  1889. — "Dr.  Wolff  explains  most 
simply  the  knotty  and  difficult  points  in  chemistry,  and  the  book  is  therefore 
well  suited  for  use  in  medical  schools." 

Medical  and  Surgical  Reporter,  Kovember,  1889. — "  AVe  could  wish  that 
more  books  like  this  would  be  written,  in  order  that  medical  students  might 
thus  early  become  more  interested  in  what  is  often  a  difficult  and  uninterest- 
ing branch  of  medical  study." 

Registered  Pharmacist,  Chicago,  December,  1890.  — "  Wolff 's  Chemistry.*' 
—  "The  author  is  thoroughly  familiar  with  hia  subjects.  A  useful  addition  to 
the  medical  and  pharmr.ceutical  library." 

15 


No.  5. 


ESSENTIALS  OE  OBSTETRICS. 


By  W.  easterly  ASHTOK,  M.D., 

Obstetrician  to  the  Philadelphia  Hospital. 


NUMEROUS  ILLUSTRATIONS.     SIXTH  THOUSAND. 


Price,  Cloth,  $1.00.     Interleaved  for  Notes,  $1.25. 

C  A 


Specimen  of  Illustrations. 

Sotitheni  Practitioner,  January,  1890. — Ashton's  Obstetrics. — An  excellent 
little  volume  containing'  correct  and  practical  knowledge.  An  admirable  cora- 
pend,  and  the  best  condensation  we  have  seen." 

Chicago  Medical  Times. — "  Ashton's  Obstetrics.— Of  extreme  value  to  stu- 
dents, and  an  excellent  little  book  to  freshen  up  the  memory  of  the  practi- 
tioner." 

Medical  and  Surgical  Reporter,  January  26,  1889. — "Ashton's  Obstetrics. 
— A  work  thoroughly  calculated  to  be  of  service  to  students  in  preparing  for 
examination.'* 

New  Torh  Medical  Abstract,  April,  1890. — "Ashton's  Obstetrics  should  be 
consulted  by  the  medical  student  until  he  can  answer  every  question  at  sight. 
The  practitioner  would  also  do  well  to  glance  at  the  book  now  and  then,  to 
prevent  his  knowledge  from  getting  rusty." 

16 


No.  6. 


ESSENTIALS 

OF 

Pathology  and  Morbid  Anatomy. 


BY 


C.  E.  ARMAND  SEMPLE,  B.A.,  M.B.,  Cantab.,  L.S.A.,  M.R.C.P.,  Lond., 

Physician  to  the  Northeastern  Hospital  for  Children,  Harkney  ;   Pro- 
fessor of  Vocal  and  Aural  Physiology  and  Examiner  in  Acous- 
tics at  Trinity  College,  London,  etc.  etc. 


ILLUSTRATED.    FOURTH  THOUSAND. 


Price,  Cloth 9  $1.00,    Interleaved  for  Notes,  $1.25. 

From  the  College  aiid  Clinical  Record, 
September,  1889. — "  A  small  work  upon 
Pathology  and  Morbid  Anatomy,  that  re- 
duces such  complex  subjects  to  the  ready 
comprehension  of  the  student  and  practi- 
tioner is  a  very  acceptable  addition  to 
medical  literature.  All  the  more  modern 
topics,  such  as  Bacteria  and  Bacilli,  and 
the  most  recent  views  as  to  Urinary  Path- 
ology, find  a  place  here,  and  in  the  hands 
of  a  writer  and  teacher  skilled  in  the  art 
of  simplifying  abstruse  and  difficult  sub- 
jects for  easy  comprehension  are  rendered 
thoroughly  intelligible.  Few  physicians 
do  more  than  refer  to  the  more  elaborate 
works  for  passing  information  at  the  time 
it  is  absolutely  needed,  but  a  book  like  this 
of  Dr.  Femple's  can  be  taken  up  and  perused  continuously  to  the  profit  and 
instruction  of  the  reader." 

Indiana.  Medieal  Journal,  December.  1889.— "  Semple's  Pathology  and 
Morbid  Anatomy.— An  excellent  compend  of  the  subject  from  the  points  of 
view  of  Green  and  Payne.'* 

Cincinnati  Medical  Neivs,  November,  1889.— Semple's  Pathology  and  Mor- 
bid Anatomy.— A  valuable  little  volume— truly  a  mnltzim  t7i parvo." 

17 


Specimen  of  Illustrations. 


ESSENTIALS 

OP 

Materia  Medica,  Therapeutics, 

AND 

PRESCRIPTION  WRITING. 


BY 


HENKY  MORRIS,  M.D., 

Late  Demonstrator,  Jefferson  Medical  College  ;  Fellow  College  of  Physicians, 

Philadelphia ;  Co-editor  Biddle*s  Materia  Medica ;  Visiting 

Physician  to  St.  Joseph's  Hospital,  etc.  etc. 


SECOND  EDITION.     FOURTH  THOUSAND. 


Price,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


Medical  and  Surgical  Reporter,  October,  1889. 

"Morris*  Materia  Medica  and  Therapeutics. — One  of  the  best  compends  in 
this  series.  Concise,  pithy,  and  clear,  well-suited  to  the  purpose  for  which  it 
is  prepared.  *' 

Gaillard*s  Medical  Journal,  November,  1889. 

"  Morris*  Materia  Medica. — The  very  essence  of  Materia  Medica  and  Thera- 
pentics  boiled  down  and  presented  in  a  clear  and  readable  style." 

Sanitarium,  New  York,  January,  1890. 
"Morris*  Materia   Medica.— A  well-arranged  quiz-book,   comprising  the 
most  important  recent  remedies.*' 

Buffalo  Medical  and  Surgical  Journal,  January,  1890. 
"Morris*  Materia  Medica. — The  subjects  are  treated  in  such  a  unique  and 
attractive  manner  that  they  cannot  fail  to  impress  the  mind  and  instruct  ir 
a  lasting  manner.'* 

18 


Nos.  8  and  9. 

Essentials  of  Practice  of  Medicine. 

By  henry  morris,  M.D., 

Author  of  "  Essentials  of  Materia  Medica,"  etc. 

With  an  Appendix  on  the  Clinical  and  Microscopical 
Examination  of  Urine. 

By  LAWRENCE  WOLEF,  M.D., 

Author  of  "Essentials  of  Medical  Chemistry,"  etc. 


COLORED  (VOGEL)  URINE  SCALE  AND  NUMEROUS 
FINE  ILLUSTRATIONS. 


8ECOND    EDITION, 

Enlarged  by  some  THREE   HUNDRED  Essential 

Formulae,  selected  from  the  writings  of  the 

most  eminent  authorities  of  the 

Medical  Profession. 

COLLECTED  AND  ARRANGED  BY 

WILLIAM  M.  POWELL,  M.D., 

Author  of  "Essentials  of  Diseases  of  Children.'' 


Price,  Clotli,  $2.00.    Medical  Sheep,  $2.50. 

Southern  Practitioner,  Nashville,  Tenn.,  January,  1891. 
"Morris*  Practice  of  Medicine. — Of  material  aid  to  the  advanced  student 
in  preparing  for  his  degree,  and  to  the  young  practitioner  in  diagnosing  affec- 
tions or  selecting  the  proper  remedy." 

American  Practitioner  and  News,  Louisville,  Ky.,  January,  1891. 
"Morris'  Practice  of  Medicine. — The  teaching  is  sound,  the  presentation 
graphic,  matter  as  full  as  might  be  desired,  and  the  style  attractive." 

Southern  Medical  Record,  January,  1891. 
"Morris'  Practice  of  Medicine  is  presented  to  the  reader  in  the  form  of 
Questions  and  Answers,  thereby  calling  attention  to  the  most  important  lead- 
ing facts,  which  is  not  only  desirable,  but  indispensable  to  an  acquaintance 
with  the  essentials  of  medicine.  The  book  is  all  it  pretends  to  be,  and  we 
cheerfully  recommend  it  to  medical  students." 

19 


No.  10. 


ESSENTIALS  OF  GYNAECOLOGY. 


BY 


EDWIN  B.  CRAIGIX,  M.D., 

Attending   Gynaecologist,    Roosevelt    Hospital,    Out- Patients'    Department ; 
Assistant  Surgeon,  New  York  Cancer  Hospital,  etc.  etc. 

58  FINE  ILLUSTRATIONS. 
SIXTH  THOUSAND. 


Price,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


Specimen  of  Illustrations. 


Medical  and  Surgical  Re- 
porter, April,1890.— "Craig- 
gin's  Essentials  of  Gryuaecol- 
ogy. — This  is  a  most  excel- 
lent addition  to  this  series 
of  question  compends,  and 
properly  used  will  be  of 
great  assistance  to  the  stu- 
dent in  preparing  for  ex- 
amination. Dr.  Craigin  is 
to  he  congratulated  upon 
having  produced  in  com- 
pact form  the  Essentials  of 
Grynseculogy.  The  style  is 
concise,  and  at  the  same 
time  the  sentences  are  well 
rounded.  This  renders  the 
book  far  more  easy  to  read 
than  most  compends,  and 
adds  distinctly  to  its  value." 
College  and  Clinical  Record, 
April,  1890.  —  "  Craigin's 
Gynaecology.— Students  and 
practitioners ,  general  or  spe- 
cial, even  derive  information 
and  benefit  from  the  perusal 
and  study  of  a  carefully 
written  work  like  this." 


20 


No.  11. 

Essentials  of  Diseases  of  the  Skin. 

By  HEKRY  W.  STELWAGOi^,  M.D., 

CJinical  Lecturer  on  Dermatology  in  the  Jefferson  Medical  Colleee,  Philadel- 
phia; Physician  to  Philadelphia  Dispensary  for  Skin  Diseases;  Chief 
ot  the  Skin  Dispensary  in  the  Hospital  of  University  of  Penn- 
sylvania; Piiysician  to  Skin  Department  of  the  Howard 
Hospital ;  Lecturer  on  Dermatology  in  the  Women's 
Medical  College,  Philadelphia,  etc.  etc. 

74  ILLUSTRATIONS,  many  of  which  are  original. 

FOURTH  THOUSAND. 


Price,  Cloth,  $l.OO.    Interleaved  for  Notes,  $1.25. 


Specimen  of  Illustrations. 

New  York  Medical  Journal,  May,  1890. — "  Stelwagon's  Diseases  of  the 
Skin. — We  are  indebted  to  Philadelphia  for  another  excellent  book  on  Derma- 
tology. The  little  book  now  before  us  is  well  entitled  "Essentials  of  Derma- 
tology," and  admirably  answers  the  purpose  for  which  it  is  written."  The 
experience  of  the  reviewer  has  taught  him  that  just  such  a  book  is  needed. 
AVe  are  pleased  with  the  handsome  appearance  of  the  book,  with  its  clear 
type,  good  paper,  and  fine  wood-cuts." 

21 


No.  12. 

ESSENTIALS 


OF 


Minor  Surgery,  Bandaging,  and 
Venereal  Diseases. 

By  EDWARD  MARTIN,  A.M.,  M.D., 

Author  of  "Essentials  of  Surgery,"  etc. 

82  ILLUSTRATIONS,  mostly  specially  prepared  for  this  wcrk. 


Price,  Cloth,  $1.00.     Interleaved  for  Notes,  $1.25. 


Medical  Nevjs,  Phila- 
delphia, January  10,1891. 
'  'Martin's  Minor  Surgery, 
Bandaging,  and  Venereal 
Diseases. —  The  best  con- 
densation of  the  subjects 
of  which  it  treatsyetplaced 
before  the  profession.  The 
chapter  on  G  enito-Urinary 
Diseases,  though  short,  is 
sufficiently  complete  to 
make  them  thoroughly 
acquainted  with  the  most 
advanced  views  on  the 
subject." 

Nashville    Joxirnal    of 
Medicineaiui  Siirgery,^o- 
vember,  1890.— '  'Martin's 
Minor  Surgery,  etc., should 
be  in  the  hands  of  every 
student,  and  we  shall  per- 
sonally recommend  it  toour 
students  as  the  best  text- 
book upon  the  subject." 
Pharmaceictical  Era,  Detroit,  Michigan,  December  1,  1890. — "Martin's 
Minor  Surgery,  etc. — Especially  acceptable  to  the  general  practitioner,  who 
is  often  at  a  loss  in  cases  of  emergency  as  to  the  proper  method  of  applying  a 
bandage  to  an  injured  member." 

22 


Specimen  of  Illustrations. 


No.  13. 

ESSENTIALS 


OP 


Legal  Medicine,  Toxicology, 


AND 


BY 

C.  E.  ARMAND  SEMPLE,  M.D., 

Author  of  ♦*  Essentials  of  Pathology  and  Morbid  Anatomy." 


130  ILLUSTRATIONS. 


rrice.  Cloth $1.00. 

Interleaved  far  Notes         ....       i.A?5. 

Southern  Practitioner,  Nashville,  May,  1890. 

''Semple's  Legal  Medicine,  etc.— At  tlie  present  time,  when  the 
field  of  medical  science,  by  reason  of  rapid  progress,  becomes  so  vast, 
a  book  which  contains  the  essentials  of  any  branch  or  department  of 
it,  in  concise,  yet  readable  form,  must  of  necessity  be  of  value.  This 
little  brochure,  as  its  title  indicates,  covers  a  portion  of  medical  science 
that  is  to  a  great  extent  too  much  neglected  by  the  student,  by  reason 
of  the  vastness  of  the  entire  field  and  the  voluminous  amount  of  matter 
pertaining  to  what  he  deems  more  important  departments.  The  lead- 
ing points,  the  essentials,  are  here  summed  up  systematically  and 
clearly." 

Medical  Brief,  St.  Louis,  May,  1890. 

*'  Semple's  Legal  Medicine,  Toxicology,  and  Hygiene.— A  fair  sample 
of  Saunders'  valuable  compends  for  the  student  and  practitioner.  It 
is  handsomely  printed  and  illustrated,  and  concise  and  clear  in  its 

teachings." 

.  23 


No.  14. 

ESSEISTTIALS  OF 

Refraction  and  Diseases  of  the  Eye. 

By  EDWARD  JACKSOK,  A.M.,  M.D., 

Professor  of  Diseases  of  the  Eye  in  the  Philadelphia  Polyclinic  and  College  for 
Graduates  in  Medicine;  Member  of  the  American  Ophthalmological  So- 
ciety ;  Fellow  of  tlie  College  of  Physicians  of  Philadelphia ;  Fel- 
low of  the  American  Academy  of  Medicine,  etc.  etc. 


AND 


Essentials  of  Diseases  of  the  Nose  and  Tliroal. 

By  E.  BALDWm  GLEASON,  M.D., 

Assistant  in  the  Nose  and  Throat  Dispensary  of  the  Hospital  of  the  University 

of  Pennsylvania;  Assistant  in  the  Nose  and  Throat  Department  of  tlie 

Union  Dispensary ;  Member  of  the  German  Medical  Society, 

Philadelphia  ;  Polyclinic  Medical  Society,  etc.  etc. 

TWO  VOLUMES  IN  ONE.     PROFUSELY  ILLUSTRATED. 


Price,  Cloth,  $1.00.     Interleaved  for  Notes,  $1.25. 


University  Medical  Mag- 
azine, Philadelphia,  Octo- 
ber, 1890.— "Jackson  and 
Gleason's  Essentials  of  Dis- 
eases of  the  Eye,  Noso,  and 
Throat.  —  The  subjects 
have  been  handled  with 
skill,  and  the  student  who 
acquires  all  that  here  lays 
before  him  will  have  much 
more  than  a  foundation  for 
future  work." 

New  ^orlc  Medical  Rec- 
ord, November  15,  1890. 
—"Jaoksan  and  Gleason 
on  Diseases  of  the  Eye, 
Nose,  and  Throat.  —  A 
valuable  book  to  the  be- 
ginner in  these  branches, 
to  the  student,  to  the  busy  practitioner,  and  as  an  adjunct  to  more  thorough 
reading.      The  authors  are  capable  men,  and  as  successful  teachers  know 

what  a  student  most  needs." 

24 


Specimen  of  Eye  Illustrations. 


No.  15. 

ESSENTIALS 


OP 


DISEASES  OF  CHILDREN. 


BY 

WILLIAM  M.  POWELL,  M.D., 

Attending  Physician  to  the  Mercer  House  for  Invalid  Women,  at  Atlantic 
City,  N.  J.;  Late  Physician  to  the  Clinic  for  the  Diseases  of  Chil- 
dren in  the  Hospital  of  the  University  of  Pennsylvania  and 
St.  Clement's  Hospital ;  Instructor  in  Physical  Diag- 
nosis in  the  Medical  Department  of  the  Uni- 
versity of  Pennsylvania,  and  Chief  of 
the  Medical  Clinic  of  the  Phil- 
adelphia Polyclinic. 


Price,  Cloth $1.00. 

Interleaved  for  Notes    ....  1.25. 


Americas  Practitioner  axd  News,  Louisville,  Ky.,  December  20, 1890. 
'•  Powell's  Diseases  of  Children. — This  work  is  gotten  up  in  the 
clear  and  attractive  style  that  characterizes  the  Saunders'  Series.  It 
contains  in  appropriate  form  the  gist  of  all  the  best  works  in  the  de- 
partment to  which  it  relates." 

SoCTHEEN  Practitioner,  Nashville,  Tennessee,  November,  1890. 
"Dr.  Powell's  little  book  is  a  marvel  of  condensation.     Handsome 
binding,  good  paper,  and  clear  type  add  to  its  attractiveness." 

Annals  of  GvNiBcoLOGY,  Philadelphia,  December,  1890. 
"  Powell's  Diseases  of  Children.— The  book  contains  a  series  of  im- 
portant questions  and  answers,  which  the  student  will  find  of  great 

utility  in  the  examination  of  children." 

25 


No.  16. 

ESSENTIALS 


OP 


EXAIIIATIOI  OF  TJEIIE. 


BY 


LAWRENCE  WOLFF,  M.D., 

Author  of  "Essentials  of  Medical  Chemistry,"  etc. 


COLORED  (VOGEL)  URINE  SCALE  AND  NUMEROUS 
ILLUSTRATIONS. 


Price,  Cloth     ...     75  Cents. 


Specimen  of  Illustrations. 


University  Medical  Ma(;azixe, 
June,  1890. 
"  Wolff's  Examination  of  the 
Urine. — A  little  work  of  decided 
\       value." 

X  ?.v;^%.^  ''fJi     Medical  Record,   New  York, 
■^^ife  ^  i  August  23,  1890. 

"^^  "Wolff's    Examination    of 

Urine.  —  A  good   manual   for 

students,    well    written,    and 

answers,   categorically,   many 

questions  beginners   are  sure 

to  ask." 


Memphis  Medical  Monthly,  Memphis,  Tennessee,  June,  1890. 
**  Wolff's  Examination  of  Urine. — The  book  is  practical  in  char- 
acter, comprehensive  as  is  desirable,  and  a  useful  aid  to  the  student 

in  his  studies." 

26 


No.  18. 

ESSENTIALS 


PRACTICE  OF  PHARMACY. 


BY 


LUCIUS   E.  SAYRE, 

Professor  of  Pharmacy  and  Materia  Medica  in  the  University  of  Kansas. 


Price,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


Albany  Medical  Annals,  Albany,  N.  Y.,  November,  1890. 
"  Sayre's  Essentials  of  Pharmacy  covers  a  great  deal  of  ground  in 
small   compass.     The   matter  is  well  digested  and  arranged.     The 
research  questions  are  a  valuable  feature  of  the  book." 

American  Doctor,  Richmond,  Va.,  January,  1891. 
"  Sayre's  Essentials  of  Pharmacy.— This  very  valuable  little  manual 
covers  the  ground  in  a  most  admirable  manner.     It  contains  practical 
pharmacy  in  a  nutshell." 

National  Drug  Register,  St.  Louis,  Mo.,  December  1,  1890. 
"  Sayre's  Essentials  of  Pharmacy.— The  best  quiz  on  pharmacy  we 
have  yet  examined." 

Western  Drug  Record,  November  10,  1890. 
''Sayre's  Essentials  of  Pharmacy.— A  book  of  only  180  pages,  but 
pharmacy  in  a  nut-shell.     It  is  not  a  quiz-compend  compiled  to  en- 
able a  grocery  clerk  to  '  down'  a  board  of  pharmacy ;  it  is  a  finger- 
post  guiding  a  student  to  a  completer  knowledge." 

27 


Saunders'  Question-Compends. 

In  Preparation.    Ready  about  September  1,  1891. 


No.  17- 

Essentials  of  Diagnosis. 

No.  19 

Essentials  of  Hygiene. 

ILLUSTRATED. 

By  ROBERT  P.  ROBINS,  M.D. 


No.  30. 


Essentials  of  Bacteriology. 

ILLUSTRATED. 

By  M.  V.  BALL,  M.D. 


No.  21. 

Essentials  of  Nervous  Diseases  and  Insanity. 

ILLUSTRATED. 

By  JOHN  C.  SHAW,  M.D. 


No.  Q2. 


Essentials  of  Medical  Physics. 

ILLUSTRATED. 

By  FRED    J    BROCKWAY,  M.D. 


No.  93. 


Essentials  of  Medical  Electricity. 

ILLUSTRATED. 

By  DAVID  D.  STEWART,  M.D.,  and  EDWARD  S.  LAWRENCE,  M.D. 


OTHERS   PREPARING. 

28 


The  Fiske  Fund  Prize  Essay  for  1890. 

THE 

SURGICAL  TREATMENT 

OP 

Wounds  and  Obstruction 

OF    THE 

INTESTINES. 

BY 

EDWARD  MARTIN,  A.M.,  M.D!, 

Clinical  Professor  of  Genito-Urinary  Diseases,  Instructor  in  Operative  Sur- 
gery, and  Lecturer  on  Minor  Surgery,  University  of  Pennsylvania; 
Surgeon  to  the  Howard  Hospital ;  Assistant  Surgeon  to  the 
University  Hospital,  etc.  etc. 

AND 

HOBART   A.  HARE,  M.D., 

Professor  of  Therapeutics,  Jefferson  Medical  College ;   Attending  Physician 
to  St.  Agnes'  Hospital. 


ILLUSTRATED. 


Price,  Cloth $2.00,  Net. 

*'  In  presenting  this  Essay  upon  the  Surgical  Treatment  of  Wounds 
and  Obstruction  of  the  Intestines  to  the  Trustees  of  the  Fiske  Fund, 
it  is  proper  to  outline  the  scope  of  our  work,  and  to  state  briefly  the 
facts  and  lines  of  original  research  upon  which  our  conclusions  are 
based.  For  over  two  years  we  have  made  experiments  in  the  labo- 
ratory upon  these  subjects,  and  have  carried  out  in  every  detail  all 
the  methods  and  modifications  of  operations  that  have  been  published 
or  which  have  occurred  to  us  in  the  course  of  our  own  studies.  .  .  . 
In  addition  to  the  original  work  involved  in  studying  so  important 
a  branch  of  surgery  as  the  one  before  us  (and  which  will  be  found 
represented,  graphically,  in  part  at  least  by  a  number  of  tracings), 
we  have  collected  and  placed  before  the  reader  what  we  believe  to  be 
the  fullest  statistics  yet  collected  upon  gunshot  wounds  of  the  abdo- 
men."— Extract  from  Preface. 

29 


IN3DEX. 


PAGE 

Announcement i 

American  Text-Book  of  Surgery        .        .        .        .  2,  3 

YlERORDT  and   StU ART'S  MEDICAL  DIAGNOSIS         .  .        4 

Keating's  New  Unabridged  Dictionary  or  Medicine  5 
Saunders'  Pocket  Medical  Lexicon  ....  6 
Kancrede's  Anatomy  and  Manual  of  Dissection  .  7 
DeSchweinitz's  Diseases  of  the  Eye  ....      8 

Garrigue's  Diseases  of  Women 9 

NoRRis'  Syllabus  of  Obstetrical  Lectures  .  .  9 
Saunders'  Pocket  Medical  Formulary  .  .  .10 
Saunders'  Series  of  Question  Compends    .        .        .11 

Hare's  Physiology 12 

Martin's  Surgery 13 

Nancrede's  Anatomy 14 

Wolff's  Chemistry 15 

Ashton's  Obstetrics 16 

Semple's  Pathology,  etc 17 

MoRHis'  Materia  Medic  a 18 

Morris'  Practice  of  Medicine 19 

Cragin's  Gynecology .20 

Stelwagen's  Diseases  of  the  Skin       .        .        .        .21 

Martin's  Minor  Surgery,  etc 22 

Semple's  Legal  Medicine,  etc.     .        .        .        .        .     23 

Jackson  and  Gleason's  Diseases  of  Eye,  Kose,  and 

Throat 24 

Powell's  Diseases  of  Children 25 

Wolff's  Examination  of  Urine 26 

Sayre's  Practice  of  Pharmacy 27 

Works  in  Preparation  and  in  Press  .        .        .28 

Martin   and  Hare's  Wounds  and  Obstruction  of 

the  Intestines 29 

3U 


THE 

CLIMATOLOGIST. 

A  MONTHLY  JOURNAL  OF  MEDICINE 

DEVOTED  TO  THE 

Relation  of  Climate,   Mineral  Springs,   Diet,  Pre- 
ventive Medicine,  Race,  Occupation,  Life 
Insurance  and  Sanitary  Science 
to  Disease. 


Edited  by 

JOHN    M.    KEATING,    M.  D. 
FREDERICK  A.  PACKARD,  M.  D.    CHAS.  F.  GARDINER,  M.  D. 


ASSOCIATE    EDITORS: 


NORMAN  BRIDGE,  M.D., 

Los  Angeles,  Cal. 
VINCENT  Y.  BOWDITCH,  M.  D. 

Boston,  Mass. 
SAML.  R.  BURROUGHS,  M.D., 

Raymond,  Tex. 
J.  WELLINGTON  BYEKS,  M.D., 

Charlotte,  N.  C. 
J.  M.  DaCOSTA,  M.D., 

Philadelphia,  Pa. 
CHARLES  DENISON,  M.l)., 

Denver,  Colo. 
GEORGE  DOCK,  M.O., 

Galveston,  Texas. 
WM.  A.  EDWARDS,  M.D., 

San  Diego,  Cal. 
J.  T.  ESKRIDGE,  M.D., 

Denver,  Colo. 
S  4MUEL  A.  EISK,  M.D.. 

Denver,  Colo. 
W.  H.  GEDDINGS,  M.D., 

Aiken,  S.  C. 
JOHN  B.  HAMILTON,  M.D., 

Chicago,  III. 
T.  S.  HOPKINS,  M.D., 

Thomas ville,  Ga. 
FREDERICK  I.  KNIGIIT.,  M.D., 

Boston,  Mass. 
B.  L.  MacDONNELL.  M.D., 

Montreal,  Canada. 


FRANCIS  MINOT,  M.D.,Boston,M:iss. 
ALFRED  L.  LOOMIS,  M.D  . 

New  York  City. 
HENRY  M.  LYMAN,  M.D., 

Chicago,  Ills. 
WILLIAM  OSLER,  M.D., 

Baltimore,  Md. 
WILLIAM  PEPPER,  M.D., 

Philadelphia,  Pa. 
BOARDMAN  REED,  M.D., 

Atlantic  City,  N.  J. 
J.  REED,  Jk.,  MD., 

Co'orado  Springs,  Colo. 
GEORGE  H.  ROHE,  M.D., 

Baltimore,  Md. 
KARL  VON  RUCK,  M.D., 

Asheville,  N.  C. 
FREDK.  C.  SHATTUCK,  M.D., 

Boston,  Mass. 
S.  E.  SOLLY,  M.D., 

Colorado  Springs,  Colo. 
G.  B.  THORNTON,  M.D., 

Memphis,  Tenn. 
E.  L.  TRUDEAU,  M.D., 

Saranac  Luke,  N.  Y. 
J,  B.  WALKER,  M.  D., 

Philadelphia,  Pa. 
J.  P.  WALL,  M.D.,  Tampa,  Florida. 
JAMES  C.  WILSON,  M.D. , 

Philadelphia,  Pa. 


Yearly  Subscription  $2.00.       Single  Numbers  20  Cts. 


W.    B.    SAUNDERS,    Publisher, 

913  Walnut  Street,  Philadelphia,  Pa. 


EXTRACT    FROM    THE    INTRODUCTION    IN  THE    OPENING 

NUMBER  OF 

"THE  CLIMATOLOGIST." 

AUGUST,  1891. 


"  The  object  of  this  Journal  is  to  promote  original  investi- 
gation, to  publish  papers  containing  the  observations  and  ex- 
perience of  physicians  in  this  country  and  Europe  on  all  matters 
relating  to  Climatology,  Mineral  Springs,  Diet,  Preventive 
Medicine,  Race,  Occupation,  Life  Insurance,  and  Sanitary 
Science — and  in  that  way  to  supply  the  means  by  which  the 
general  practitioner  and  the  public  at  large  will  become  better 
acquainted  with  the  diseases  of  this  country  and  Europe,  and 
better  armed  to  meet  the  requirements  of  their  prevention  or 
cure.  The  study  of  these  subjects  in  this  country  is  exciting 
great  and  increasing  interest,  and  all  admit  that,  from  the  little 
knowledge  already  possessed  of  its  resources,  possibly  every 
known  combination  of  atmospheric  condition,  soil,  altitude,  cli- 
mate, or  mineral  springs,  is  to  be  found  on  this  continent.  It  is 
confidently  expected  that  such  di  journal  w\\\  receive  encourage- 
ment and  be  an  authority  upon  all  questions  which  are  included 
in  its  title. 

'*  Original  papers  upon  diseases  of  localities — those  incident 
to  occupation,  race,  or  climate,  the  study  of  epidemics,  the 
questions  of  proper  food,  of  the  water  supply,  its  potability 
and  distribution,  matters  relating  to  drainage  and  diseases  de- 
pendent on  it — as  well  as  experimental  studies,  or  laboratory 
investigations  on  bacteriology,  will  form  a  prominent  portion 
of  the  material  presented  during  the  year,  and  it  is  to  be  hoped 
that  physicians  of  all  sections  of  the  country  will  send  papers 
upon  these  or  any  other  subjects  which  will  be  of  general  in- 
terest. 

"  Special  attention  will  also  be  paid  to  the  subject  of  health 
resorts,  descriptions  of  Sanitariums  with  special  reference  to 
their  suitability  to  certain  cases,  and  the  proper  selection  of 
patients  likely  to  be  benefitted  by  them.  The  utmost  care  will 
be  taken  that  this  Journal  shall  assume  and  maintain  the 
highest  scientific  character.  It  will  be  absolutely  independent 
in  its  principles^3/i3:/r  tozvards  all.  It  will  depend  for  its  main- 
tenance upon  the  support  given  to  it  by  the  prefession,  as  it  is 
not  published  in  the  interest  of  any  special  section  or  clique." 


&.AJWlsrTDlE2-JE=L&' 


POCKET  MEDICAL  LEXICON; 

OR, 

Dictionary  of  Terms  and  Words  used  in  IVIedicii#  and  Surgery, 

By  JOHN  M.  KEATING,  M.D., 

Editor  of  "  Cyclopijedia  of  Diseases  of  Cliildren,"  etc. ;  Author  of  the 
"New  Pronouncing  Dictionary  of  Medicine," 

AND 

HENRY  HAMILTON, 

Author  of  "A  New  Translation  of  Virgil's  vEneid  into  English  Verse;" 
Co-author  of  a  "  New  Pronouncing  Dictionary  of  Medicine." 


Price,  75  Cents,  Cloth.    $1.00,  Leather  Tucks. 


>JoihltppotiUX.^f.S 


effracert 


$o   _J 

do  . 

70    . 

€o 

SO 

40 

JO 

eo 


^o 


i^waten 


-  10 


-Zo 


f7€ 
f58 
Mo 
t2Z 
/04 
V-S6 


80* 


—  72 


_  /76       _  6^ 
^3Z 


Tins  new  and  compreheiisive 
work  of  reference  is  the  outcome 
of  a  demand  for  a  more  modern 
handbook  of  its  class  than  these 
at  present  on  themarket,which, 
dating  as  they  do  from  1855  to 
1884,  are  of  but  trifling  use  to 
the  student  by  their  not  con- 
taining the  hundreds  of  new 
words  now  used  in  current  lit- 
erature, especially  those  relat- 
ing to  Electricity  and  Bacteri- 
ology. 


^69        _  /» 


SO 


.JZ' 


—  f^       —8 


u 


(From  Appendix  to  Medical  Lexicon.) 

6 


Annals  of  Gyncecology,  Phila- 

—  ^  delphia,  December,  1890. 

Saunders'  Pocket  Medical  Lexi- 

—  ^  con— a  very  complete  little  work, 
invaluable  to  every  student  of 
medicine.  It  not  only  contains  a 
very  large  number  of  words,  but 
also  tables  of  etymological  factors 
common  in  medical  terminology  ; 
abbreviations  used  in  medicine, 
poisons  and  antidotes,  etc. 


—  liT 


SECOND    EPmON. 

HOW  TO  EXAMINE  FOR  LIFE  INSURANCE. 

By  JOHN  M.  KEATING,  M.D., 

Medical  Director  Penn  Mutual  Life  Insurance  Co.  ;  Ex-President  of  the  Association  of  Life 

Insurance  Medical  Directors  ;  Consulting  Physician  for  Diseases  of  Women  at  St. 

Agnes'  Hospital,  Phila.  ;  Gynaecologist  to  St.  Joseph's  Hospital,  etc. 

With  two  large  Phototype  Illustrations,  and  a  Plate  prepared  by  Dr.  McClellau 
from  special  Dissections ;  also,  numerous  cuts  to  elucidate  the  text. 

Price,    in    Oloth,     ^S.OO. 

PART  I.  has  been  carefully  prepared  from  the  best  works  on  physical  diagnosis, 
and  is  a  short  and  succinct  account  of  the  methods  used  to  make  examina- 
tions; a  description  of  the  normal  condition,  and  of  the  earliest  evidences  of 
disease. 

PART  II.  contains  the  instructions  of  twenty-four  Life  Insurance  Companies  to 
their  medical  examiners. 


PRESS  NOTICES.  , 

"  This  is  the  most  practical  manual  on  this  subject  that  has  yet  been  offered  as 
a  guide  to  the  medical  examiner  for  life  insurance.  The  author  has  had  a  large 
experience  as  a  medical  director  of  one  of  the  great  life  insurance  companies, 
and  it  would,  therefore,  naturally  be  expected  that  he  would  deal  with,  nothing 
but  the  useful  and  indispensable  in  a  work  of  this  kind.  Every  life  insurance 
examiner  should  possess  this  book,  even  though  he  may  be  experienced  in  this 
work,  for  it  contains  much  that  is  needful  in  the  way  of  reference  that  cannot  be 
found  grouped  elsewhere." — Buffalo  Medical  and  Surgical  Journal.^ 

"This  unpretentious  volume,  from  the  pen  of  one  of  our  most  experienced  and 
conservative  life  insurance  medical  directors,  is  just  such  a  book  as  the  young  and 
inexperienced  medical  examiner  needs.  It  is  not  a  manual  of  Medical  diagnosis, 
though  founded  upon  the  best  works  of  that  description.  It  contains  those  sug- 
gestive hints  and  recommendations  that  will  be  useful  to  the  medical  beginner 
and  that  can  only  be  furnished  by  the  man  of  experience." — The  American 
yoiirnal  of  the  Medical  Sciences. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance 
examination,  a  subject  of  growing  interest  and  importance.  Not  the  least  valu- 
able portion  of  the  volume  is  Part  IL,  which  consists  of  instructions  issued  to 
their  examining  physicians  by  twenty-four  representative  companies  of  this  conn- 
try.  As  the  proofs  of  these  instructions  were  corrected  by  the  directors  of  the 
companies,  they  form  the  latest  instructions  obtainable.  If  for  these  alone,  the 
book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special 
branch  of  medical  science." — The  Medical  News. 

"The  volume  is  replete  with  information  and  suggestions,  and  is  a  valuable 
contribution  to  the  literature  of  the  medical  department  of  life  underwriters'  work. 
—  The  Wnited  Stales  Review  {\n=,\\r2ince  ]o\xrr\2^.). 

"  Naturally,  in  the  prevailing  scheme  of  medical  education,  special  instruction 
in  the  peculiar  duties  of  the  insurance  examiner  can  have  no  place;  The  young 
physician  may  be  never  so  good  a  diagnostician  or  pathologist,  and  yet  fail,  to  give 
satisfaction  as  a  medical  examiner.  The  book  before  us  fills  this  want."— 77^^ 
University  Medical  Magazine. 

Sent  post-paid  on  receipt  of  price  by  the  publisher, 

W.  B.  SAUNDERS, 
913  Walnut  Street,  Phila.,  Pa. 


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